Prescription drug

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Photo of the packaging of four medicines registered in the UK, showing their Product Licence Numbers and symbols denoting if they are Prescription Only Medicine (POM) or Pharmacy Medicine (P) PLcodes.jpg
Photo of the packaging of four medicines registered in the UK, showing their Product Licence Numbers and symbols denoting if they are Prescription Only Medicine (POM) or Pharmacy Medicine (P)

A prescription drug (also prescription medication, prescription medicine or prescription-only medication) is a pharmaceutical drug that is permitted to be dispensed only to those with a medical prescription. In contrast, over-the-counter drugs can be obtained without a prescription. The reason for this difference in substance control is the potential scope of misuse, from drug abuse to practicing medicine without a license and without sufficient education. Different jurisdictions have different definitions of what constitutes a prescription drug.

Contents

In North America, ℞, usually printed as "Rx", is used as an abbreviation of the word "prescription". It is a contraction of the Latin word "recipe" (an imperative form of "recipere") meaning "take". [1] Prescription drugs are often dispensed together with a monograph (in Europe, a Patient Information Leaflet or PIL) that gives detailed information about the drug.

The use of prescription drugs has been increasing since the 1960s.

Regulation

Australia

In Australia, the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP) governs the manufacture and supply of drugs with several categories: [2]

As in other developed countries, the person requiring a prescription drug attends the clinic of a qualified health practitioner, such as a physician, who may write the prescription for the required drug.

Many prescriptions issued by health practitioners in Australia are covered by the Pharmaceutical Benefits Scheme, a scheme that provides subsidised prescription drugs to residents of Australia to ensure that all Australians have affordable and reliable access to a wide range of necessary medicines. When purchasing a drug under the PBS, the consumer pays no more than the patient co-payment contribution, which, as of January 1, 2022, is A$42.50 for general patients. Those covered by government entitlements (low-income earners, welfare recipients, Health Care Card holders, etc.) and or under the Repatriation Pharmaceutical Benefits Scheme (RPBS) have a reduced co-payment, which is A$6.80 in 2022. [3] The co-payments are compulsory and can be discounted by pharmacies up to a maximum of A$1.00 at cost to the pharmacy.

United Kingdom

In the United Kingdom, the Medicines Act 1968 and the Prescription Only Medicines (Human Use) Order 1997 contain regulations that cover the supply of sale, use, prescribing and production of medicines. There are three categories of medicine: [4]

The simple possession of a prescription-only medicine without a prescription is legal unless it is covered by the Misuse of Drugs Act 1971. [5]

A patient visits a medical practitioner or dentist, who may prescribe drugs and certain other medical items, such as blood glucose-testing equipment for diabetics. Also, qualified and experienced nurses, paramedics and pharmacists may be independent prescribers. Both may prescribe all POMs (including controlled drugs), but may not prescribe Schedule 1 controlled drugs, and 3 listed controlled drugs for the treatment of addiction; which is similar to doctors, who require a special license from the Home Office to prescribe schedule 1 drugs. Schedule 1 drugs have little or no medical benefit, hence their limitations on prescribing. District nurses and health visitors have had limited prescribing rights since the mid-1990s; until then, prescriptions for dressings and simple medicines had to be signed by a doctor. Once issued, a prescription is taken by the patient to a pharmacy, which dispenses the medicine.

Most prescriptions are NHS prescriptions, subject to a standard charge that is unrelated to what is dispensed. The NHS prescription fee was increased to £9.90 for each item in England in May 2024; [6] prescriptions are free of charge if prescribed and dispensed in Scotland, [7] Wales and Northern Ireland, [8] and for some patients in England, such as inpatients, children, those over 60s or with certain medical conditions, and claimants of certain benefits. [9] The pharmacy charges the NHS the actual cost of the medicine, which may vary from a few pence to hundreds of pounds. [10] [11] A patient can consolidate prescription charges by using a prescription payment certificate (informally a "season ticket"), effectively capping costs at £31.25 a quarter or £111.60 for a year. [9]

Outside the NHS, private prescriptions are issued by private medical practitioner and sometimes under the NHS for medicines that are not covered by the NHS. [10] [11] A patient pays the pharmacy the normal price for medicine prescribed outside the NHS.

Survey results published by Ipsos MORI in 2008 found that around 800,000 people in England were not collecting prescriptions or getting them dispensed because of the cost, the same as in 2001. [12]

United States

In the United States, the Federal Food, Drug, and Cosmetic Act defines what substances, known as legend drugs, require a prescription for them to be dispensed by a pharmacy. The federal government authorizes physicians (of any specialty), physician assistants, nurse practitioners and other advanced practice nurses, veterinarians, dentists, and optometrists to prescribe any controlled substance. They are issued unique DEA numbers. [13] Many other mental and physical health technicians, including basic-level registered nurses, medical assistants, emergency medical technicians, most psychologists, and social workers, are not authorized to prescribe legend drugs. [14]

The federal Controlled Substances Act (CSA) was enacted in 1970. It regulates manufacture, importation, possession, use, and distribution of controlled substances, which are drugs with potential for abuse or addiction. The legislation classifies these drugs into five schedules, with varying qualifications for each schedule. The schedules are designated schedule I, schedule II, schedule III, schedule IV, and schedule V. Many drugs other than controlled substances require a prescription.

The safety and the effectiveness of prescription drugs in the US are regulated by the 1987 Prescription Drug Marketing Act (PDMA). The Food and Drug Administration (FDA) is charged with implementing the law.

As a general rule, over-the-counter drugs (OTC) are used to treat a condition that does not need care from a healthcare professional if have been proven to meet higher safety standards for self-medication by patients. Often, a lower strength of a drug will be approved for OTC use, but higher strengths require a prescription to be obtained; a notable case is ibuprofen, which has been widely available as an OTC pain killer since the mid-1980s, but it is available by prescription in doses up to four times the OTC dose for severe pain that is not adequately controlled by the OTC strength.

Herbal preparations, amino acids, vitamins, minerals, and other food supplements are regulated by the FDA as dietary supplements. Because specific health claims cannot be made, the consumer must make informed decisions when purchasing such products. [15]

By law, American pharmacies operated by "membership clubs" such as Costco and Sam's Club must allow non-members to use their pharmacy services and may not charge more for these services than they charge as their members.[ citation needed ]

Physicians may legally prescribe drugs for uses other than those specified in the FDA approval, known as off-label use.[ citation needed ] Drug companies, however, are prohibited from marketing their drugs for off-label uses.[ citation needed ]

Some prescription drugs are commonly abused, particularly those marketed as analgesics, including fentanyl (Duragesic), hydrocodone (Vicodin), oxycodone (OxyContin), oxymorphone (Opana), propoxyphene (Darvon), hydromorphone (Dilaudid), meperidine (Demerol), and diphenoxylate (Lomotil). [16]

Some prescription painkillers have been found to be addictive, and unintentional poisoning deaths in the United States have skyrocketed since the 1990s according to the National Safety Council. [17] Prescriber education guidelines as well as patient education, prescription drug monitoring programs and regulation of pain clinics are regulatory tactics which have been used to curtail opioid use and misuse. [18]

Expiration date

The expiration date, required in several countries, specifies the date up to which the manufacturer guarantees the full potency and safety of a drug. In the United States, expiration dates are determined by regulations established by the FDA. [19] The FDA advises consumers not to use products after their expiration dates. [20]

A study conducted by the U.S. Food and Drug Administration covered over 100 drugs, prescription and over-the-counter. The results showed that about 90% of them were safe and effective far past their original expiration date. At least one drug worked 15 years after its expiration date. [21] Joel Davis, a former FDA expiration-date compliance chief, said that with a handful of exceptions—notably nitroglycerin, insulin, and some liquid antibiotics (outdated tetracyclines can cause Fanconi syndrome)—most expired drugs are probably effective. [22]

The American Medical Association issued a report and statement on Pharmaceutical Expiration Dates. [23] The Harvard Medical School Family Health Guide notes that, with rare exceptions, "it's true the effectiveness of a drug may decrease over time, but much of the original potency still remains even a decade after the expiration date". [24]

The expiration date is the final day that the manufacturer guarantees the full potency and safety of a medication. Drug expiration dates exist on most medication labels, including prescription, over-the-counter and dietary supplements. U.S. pharmaceutical manufacturers are required by law to place expiration dates on prescription products prior to marketing. For legal and liability reasons, manufacturers will not make recommendations about the stability of drugs past the original expiration date. [25]

Cost

Prices of prescription drugs vary widely around the world. Prescription costs for biosimilar and generic drugs are usually less than brand names, but the cost is different from one pharmacy to another.

To lower prescription drug costs, some U.S. states have sought federal approval to buy drugs in Canada, as of 2022. [26]

Generics undergo strict scrutiny to meet the equal efficacy, safety, dosage, strength, stability, and quality of brand name drugs. [27] Generics are developed after the brand name has already been established, and so generic drug approval in many aspects has a shortened approval process because it replicates the brand name drug. [27]

Brand name drugs cost more due to time, money, and resources that drug companies invest in them to conduct development, including clinical trials that the FDA requires for the drug to be marketed. [28] Because drug companies have to invest more in research costs to do this, brand name drug prices are much higher when sold to consumers. [28]

When the patent expires for a brand name drug, generic versions of that drug are produced by other companies and are sold for lower price. By switching to generic prescription drugs, patients can save significant amounts of money: e.g. one study by the FDA showed an example with more than 52% savings of a consumer's overall costs of their prescription drugs. [29]

Strategies to limit drug prices in the US

In the United States there are many resources available to patients to lower the costs of medication. These include copayments, coinsurance, and deductibles. The Medicaid Drug Rebate Program is another example. [30]

Generic drug programs lower the amount of money patients have to pay when picking up their prescription at the pharmacy. As their name implies, they only cover generic drugs. [31]

Co-pay assistance programs are programs that help patients lower the costs of specialty medications; i.e., medications that are on restricted formularies, have limited distribution, and/or have no generic version available. These medications can include drugs for HIV, hepatitis C, and multiple sclerosis. Patient Assistance Program Center (RxAssist) has a list of foundations that provide co-pay assistance programs. Co-pay assistance programs are for under-insured patients. Patients without insurance are not eligible for this resource; however, they may be eligible for patient assistance programs.

Patient assistance programs are funded by the manufacturer of the medication. Patients can often apply to these programs through the manufacturer's website. This type of assistance program is one of the few options available to uninsured patients.

The out-of-pocket cost for patients enrolled in co-pay assistance or patient assistance programs is $0. It is a major resource to help lower costs of medications – however, many providers and patients are not aware of these resources.

Environment

Traces of prescription drugs — including antibiotics, anti-convulsants, mood stabilizers and sex hormones — have been detected in drinking water. [32] [33] Pharmaceutically active compounds (PhACs) discarded from human therapy and their metabolites may not be eliminated entirely by sewage treatment plants and have been detected at low concentrations in surface waters downstream from those plants. [34] The continuous discarding of incompletely treated water may interact with other environmental chemicals and lead to uncertain ecological effects. [35] Due to most pharmaceuticals being highly soluble, fish and other aquatic organisms are susceptible to their effects. [34] The long-term effects of pharmaceuticals in the environment may affect survival and reproduction of such organisms. [34] However, levels of medical drug waste in the water is at a low enough level that it is not a direct concern to human health. However, processes, such as biomagnification, are potential human health concerns. [36]

On the other hand, there is clear evidence of harm to aquatic animals and fauna. Recent advancements in technology have allowed scientists to detect smaller, trace quantities of pharmaceuticals in the ng/ml range. [37] Despite being found at low concentrations, female hormonal contraceptives may cause feminizing effects on male vertebrate species, such as fish, frogs and crocodiles. [37]

The FDA established guidelines in 2007 to inform consumers should dispose of prescription drugs. [38] When medications do not include specific disposal instructions, patients should not flush medications in the toilet, but instead use medication take-back programs to reduce the amount of pharmaceutical waste in sewage and landfills. [39] If no take-back programs are available, prescription drugs can be discarded in household trash after they are crushed or dissolved and then mixed in a separate container or sealable bag with undesirable substances like cat litter or other unappealing material (to discourage consumption). [39]

See also

Related Research Articles

<span class="mw-page-title-main">Medication</span> Substance used to diagnose, cure, treat, or prevent disease

A medication is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy (pharmacotherapy) is an important part of the medical field and relies on the science of pharmacology for continual advancement and on pharmacy for appropriate management.

<span class="mw-page-title-main">Over-the-counter drug</span> Medication available without a prescription

Over-the-counter (OTC) drugs are medicines sold directly to a consumer without a requirement for a prescription from a healthcare professional, as opposed to prescription drugs, which may be supplied only to consumers possessing a valid prescription. In many countries, OTC drugs are selected by a regulatory agency to ensure that they contain ingredients that are safe and effective when used without a physician's care. OTC drugs are usually regulated according to their active pharmaceutical ingredient (API) rather than final products. By regulating APIs instead of specific drug formulations, governments allow manufacturers the freedom to formulate ingredients, or combinations of ingredients, into proprietary mixtures.

<span class="mw-page-title-main">Pharmacy</span> Clinical health science

Pharmacy is the science and practice of discovering, producing, preparing, dispensing, reviewing and monitoring medications, aiming to ensure the safe, effective, and affordable use of medicines. It is a miscellaneous science as it links health sciences with pharmaceutical sciences and natural sciences. The professional practice is becoming more clinically oriented as most of the drugs are now manufactured by pharmaceutical industries. Based on the setting, pharmacy practice is either classified as community or institutional pharmacy. Providing direct patient care in the community of institutional pharmacies is considered clinical pharmacy.

<span class="mw-page-title-main">Medical prescription</span> Health-care communication from a physician to a pharmacist

A prescription, often abbreviated ℞ or Rx, is a formal communication from a physician or other registered healthcare professional to a pharmacist, authorizing them to dispense a specific prescription drug for a specific patient. Historically, it was a physician's instruction to an apothecary listing the materials to be compounded into a treatment—the symbol ℞ comes from the first word of a medieval prescription, Latin recipere, that gave the list of the materials to be compounded.

Prescription drug list prices in the United States continually are among the highest in the world. The high cost of prescription drugs became a major topic of discussion in the 21st century, leading up to the American health care reform debate of 2009, and received renewed attention in 2015. One major reason for high prescription drug prices in the United States relative to other countries is the inability of government-granted monopolies in the American health care sector to use their bargaining power to negotiate lower prices, and the American payer ends up subsidizing the world's R&D spending on drugs.

The Pharmaceutical Benefits Scheme (PBS) is a program of the Australian Government that subsidises prescription medication for Australian citizens and permanent residents, as well as international visitors covered by a reciprocal health care agreement. The PBS is separate to the Medicare Benefits Schedule, a list of health care services that can be claimed under Medicare, Australia's universal health care insurance scheme.

<span class="mw-page-title-main">Regulation of therapeutic goods</span> Legal management of drugs and restricted substances

The regulation of therapeutic goods, defined as drugs and therapeutic devices, varies by jurisdiction. In some countries, such as the United States, they are regulated at the national level by a single agency. In other jurisdictions they are regulated at the state level, or at both state and national levels by various bodies, as in Australia.

<span class="mw-page-title-main">Off-label use</span> Use of pharmaceuticals for conditions different from that for which they were approved

Off-label use is the use of pharmaceutical drugs for an unapproved indication or in an unapproved age group, dosage, or route of administration. Both prescription drugs and over-the-counter drugs (OTCs) can be used in off-label ways, although most studies of off-label use focus on prescription drugs.

<span class="mw-page-title-main">Sodium oxybate</span> Medication to treat symptoms of narcolepsy

Sodium oxybate, sold under the brand name Xyrem among others, is a medication used to treat symptoms of narcolepsy: sudden muscle weakness and excessive daytime sleepiness. It is used sometimes in France and Italy as an anesthetic given intravenously; it is also approved and used in Italy and in Austria to treat alcohol dependence and alcohol withdrawal syndrome.

An online pharmacy, internet pharmacy, or mail-order pharmacy is a pharmacy that operates over the Internet and sends orders to customers through mail, shipping companies, or online pharmacy web portal.

The NHS treatments blacklist is an informal name for a list of medicines and procedures which will not be funded by public money except in exceptional cases. These include but are not limited to procedures which the National Institute for Health and Care Excellence (NICE) has ruled of limited effectiveness and particular brand name medicines. In 2017 there was a proposal for 3,200 over-the-counter (OTC) drugs to be restricted and 18 procedures to be added to the list. This generated some controversy amongst doctors with some arguing that OTC should be blacklisted instead, and others believing the move did not take into account individual patient needs.

The term private prescription is a term used in the United Kingdom for a medical prescription which is not supplied under the National Health Service (NHS).

<span class="mw-page-title-main">Pharmacy (shop)</span> Shop that provides pharmaceutical drugs

A pharmacy is a retail shop which provides pharmaceutical drugs, among other products. At the pharmacy, a pharmacist oversees the fulfillment of medical prescriptions and is available to counsel patients about prescription and over-the-counter drugs or about health problems and wellness issues. A typical pharmacy would be in the commercial area of a community.

Medication costs, also known as drug costs are a common health care cost for many people and health care systems. Prescription costs are the costs to the end consumer. Medication costs are influenced by multiple factors such as patents, stakeholder influence, and marketing expenses. A number of countries including Canada, parts of Europe, and Brazil use external reference pricing as a means to compare drug prices and to determine a base price for a particular medication. Other countries use pharmacoeconomics, which looks at the cost/benefit of a product in terms of quality of life, alternative treatments, and cost reduction or avoidance in other parts of the health care system. Structures like the UK's National Institute for Health and Clinical Excellence and to a lesser extent Canada's Common Drug Review evaluate products in this way.

A formulary is a list of pharmaceutical drugs, often decided upon by a group of people, for various reasons such as insurance coverage or use at a medical facility. Traditionally, a formulary contained a collection of formulas for the compounding and testing of medication. Today, the main function of a prescription formulary is to specify particular medications that are approved to be prescribed at a particular hospital, in a particular health system, or under a particular health insurance policy. The development of prescription formularies is based on evaluations of efficacy, safety, and cost-effectiveness of drugs.

Electronic prescription is the computer-based electronic generation, transmission, and filling of a medical prescription, taking the place of paper and faxed prescriptions. E-prescribing allows a physician, physician assistant, pharmacist, or nurse practitioner to use digital prescription software to electronically transmit a new prescription or renewal authorization to a community or mail-order pharmacy. It outlines the ability to send error-free, accurate, and understandable prescriptions electronically from the healthcare provider to the pharmacy. E-prescribing is meant to reduce the risks associated with traditional prescription script writing. It is also one of the major reasons for the push for electronic medical records. By sharing medical prescription information, e-prescribing seeks to connect the patient's team of healthcare providers to facilitate knowledgeable decision making.

Automatic Generic Substitution is a proposal by the Department of Health (DH) whereby in January 2010 pharmacists could be obliged to substitute a generic version of a medication even if the prescriber had written the prescription for a specific brand, as part of a new deal on drug pricing.

Pharmacy in the United Kingdom has been an integral part of the National Health Service since it was established in 1948. Unlike the rest of the NHS, pharmacies are largely privately provided apart from those in hospitals, and even these are now often privately run.

<span class="mw-page-title-main">Drug labelling</span>

Drug labelling is also referred to as prescription labelling, is a written, printed or graphic matter upon any drugs or any of its container, or accompanying such a drug. Drug labels seek to identify drug contents and to state specific instructions or warnings for administration, storage and disposal. Since 1800s, legislation has been advocated to stipulate the formats of drug labelling due to the demand for an equitable trading platform, the need of identification of toxins and the awareness of public health. Variations in healthcare system, drug incidents and commercial utilization may attribute to different regional or national drug label requirements. Despite the advancement in drug labelling, medication errors are partly associated with undesirable drug label formatting.

The Swiss dispensing category regulates which kinds of drugs can be dispensed by the pharmacist, and whether a prescription is necessary. Swissmedic, the Swiss authority for approving drugs, classifies the drugs under the appropriate category.

References

  1. ↑ "Rx". Merriam Webster Dictionary. Retrieved 16 April 2021.
  2. ↑ "The Poisons Standard (the SUSMP)". Therapeutic Goods Administration . Retrieved 17 September 2011.
  3. ↑ "About the PBS". Pharmaceutical Benefits Scheme . Retrieved 26 September 2022.
  4. ↑ "About Registration: Medicines and Prescribing". Health and Care Professions Council. Archived from the original on 13 January 2016. Retrieved 15 February 2015.
  5. ↑ "Other drug laws". Home Office. Archived from the original on 19 April 2010.
  6. ↑ "How Much is the NHS Prescription Charge?". NHS Choices. Retrieved 15 June 2020.
  7. ↑ "Staged end to prescription charge". BBC News . 5 December 2007.
  8. ↑ "[NI] Prescription charges". NI Direct. Archived from the original on 29 August 2011. Retrieved 12 July 2011.
  9. 1 2 "NHS in England - help with health costs". nhs.uk. NHS. NHS Choices. Retrieved 15 February 2017.
  10. 1 2 "Patients and prescribing: rights and responsibilities". British Medical Association. 23 March 2006. Archived from the original on 9 January 2009. Retrieved 18 April 2010.
  11. 1 2 "Information and guidance on prescribing in general practice" (PDF). British Medical Association. September 2004. Archived from the original (PDF) on 2012-06-07.
  12. ↑ Ipsos MORI:Prescription Costs A Barrier To Healthcare, 27 February 2008
  13. ↑ "Registration". DEA Diversion Control Division. 2017-07-14. Retrieved 2021-09-14.
  14. ↑ "US Nurse Practitioner Prescribing Law: A State-by-State Summary". Medscape Nurses. 2 November 2010. Retrieved 26 November 2010.
  15. ↑ Alexander, GC; O'Connor, AB; Stafford, RS (2011). "Enhancing prescription drug innovation and adoption". Annals of Internal Medicine. 154 (12): 833–837. doi:10.7326/0003-4819-154-12-201106210-00012. PMC   4049188 . PMID   21690598.
  16. ↑ "Prescription Drugs & Cold Medicines". www.drugabuse.gov. National Institute of Health. Retrieved 12 September 2015.
  17. ↑ Injury Facts. National Safety Council. 2017. p. 161. ISBN   978-0-87912-357-4.
  18. ↑ National Safety Council (2017). The State of Safety - A State-by-State Report. Itasca, IL. Pg. 30-31. accessed at: http://www.nsc.org/NSCDocuments_Advocacy/State-of-Safety/State-Report.pdf Archived 2017-07-28 at the Wayback Machine
  19. ↑ "Questions and Answers on Current Good Manufacturing Practices, Good Guidance Practices, Level 2 Guidance - Records and Reports". United States Food and Drug Administration. 8 February 2019.
  20. ↑ "Expiration Dates Matter". United States Food and Drug Administration. 14 July 2015. Retrieved 12 September 2015.
  21. ↑ "Proceedings". Baylor Univ. Medical CTR. 13: 309.
  22. ↑ Cohen, Laurie P. (2000-03-28). "Many Medicines Prove Potent for Years Past Their Expiration Dates". The Wall Street Journal . Vol. 235, no. 62. pp. A1.
  23. ↑ "Report 1 of the Council on Scientific Affairs (A-01) Full text: Pharmaceutical Expiration Dates". American Medical Association. June 2001. Archived from the original on 2011-02-01. Retrieved 2010-04-19.
  24. ↑ Drug Expiration Dates - Do They Mean Anything?. Harvard Health Publications. Retrieved on February 15, 2011.
  25. ↑ "Drug Expiration Dates - Are Expired Drugs Still Safe to Take?". Drugs.com. 20 July 2020. Retrieved 28 July 2023.
  26. ↑ Phil Galewitz (14 December 2022). "States challenge Biden to lower drug prices by allowing imports from Canada". CBS News. Retrieved 28 July 2023.
  27. 1 2 Research, Center for Drug Evaluation and. "Questions & Answers - Generic Drugs: Questions & Answers". www.fda.gov. Retrieved 2017-10-31.
  28. 1 2 "Generic Drugs". US Food and Drug Administration. 1 November 2021. Retrieved 28 July 2023.
  29. ↑ "Savings From Generic Drugs Purchased at Retail Pharmacies". US Food and Drug Administration. 6 May 2016. Retrieved 28 July 2023.
  30. ↑ "Cost Sharing Out of Pocket Costs". Medicaid.gov. Retrieved 12 June 2018.
  31. ↑ "Generic Drug Facts". FDA. Retrieved 12 June 2018.
  32. ↑ Jeff Donn; Martha Mendoza; Justin Pritchard (2008-03-10). "Drugs found in drinking water". USA Today . Associated Press. Archived from the original on 2008-03-13. Retrieved 2011-02-15.
  33. ↑ Gray, Richard (2008-01-13). "Cancer drugs found in tap water". The Sunday Telegraph . Archived from the original on 2009-03-17. Retrieved 2010-01-19.
  34. 1 2 3 Li, W. C. (2014-04-01). "Occurrence, sources, and fate of pharmaceuticals in aquatic environment and soil". Environmental Pollution. 187 (Supplement C): 193–201. doi:10.1016/j.envpol.2014.01.015. PMID   24521932.
  35. ↑ Heberer, Thomas (2002-05-10). "Occurrence, fate, and removal of pharmaceutical residues in the aquatic environment: a review of recent research data". Toxicology Letters. 131 (1): 5–17. doi:10.1016/S0378-4274(02)00041-3. PMID   11988354.
  36. ↑ Boxall, Alistair B.A. (December 2004). "The environmental side effects of medication". EMBO Reports. 5 (12): 1110–1116. doi:10.1038/sj.embor.7400307. ISSN   1469-221X. PMC   1299201 . PMID   15577922.
  37. 1 2 Fabbri, Elena (March 2015). "Pharmaceuticals in the environment: expected and unexpected effects on aquatic fauna". Annals of the New York Academy of Sciences. 1340 (1): 20–28. Bibcode:2015NYASA1340...20F. doi:10.1111/nyas.12605. hdl: 11585/556827 . ISSN   1749-6632. PMID   25557669. S2CID   2567919.
  38. ↑ "External Medicine: Discarded Drugs May Contaminate 40 Million Americans' Drinking Water". Scientific American. Retrieved 2017-11-15.
  39. 1 2 Lubick, Naomi (May 2010). "Drugs in the Environment: Do Pharmaceutical Take-Back Programs Make a Difference?". Environmental Health Perspectives. 118 (5): A210–A214. doi:10.1289/ehp.118-a210. ISSN   0091-6765. PMC   2866706 . PMID   20435558.
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