Using the Mississippi River Watershed Module in Biological Fate of Drugs

Zoë Wagner, Bentley University

Course Description

Pharmaceutical drugs are a nearly ubiquitous part of our lives. Many of us do not hesitate to take Advil for a headache or Robitussin when we have a cough, yet we rarely think about what these drugs actually are. What is it in Advil that reduces pain? Which ingredient in Robitussin eases a cough? How do we ensure that the drugs that are available over the counter and by prescription are safe and effective? Who gets to decide what drugs are approved and which are not? This course will cover the process of drug discovery, where we find new drugs, and how these drugs are approved by the FDA. We will look at the clinical information used to drive approval decisions and look at how drugs are priced and marketed to the public.

We will then transition to a closer analysis of how drugs actually work in the body. This course will analyze how drugs are able to have systemic, whole-body effects, while (hopefully) targeting a specific disease or condition. We will look at what drugs actually are, and how their chemical structure will impact their ability cause a biological effect. We will end with an investigation into where drugs end up once taken – why can we find antibiotics in most drinking water, and what can we do about it?

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Relationship of the Mississippi Watershed Module to Your Course

The course had 26 sessions, of which one was devoted to bridging between the course content and BASICS module and four were devoted to the BASICS module itself. The module was the final element of the course, comprising the final two and a half weeks of the semester. We ended the semester with a discussion of where do drugs go after they have been cleared by the kidney? So we discussed drug clearance in urine, where wastewater goes, and then the impact of wastewater treatment on the concentration of various pharmaceuticals. We then talked about estimates of pharmaceutical concentrations in drinking water, and ways to remove the drugs from water. The final course-specific element was a class discussion centered around the question of do we care that there are pharmaceuticals in the water? Given the measured concentrations, given the fraction that is absorbed in the body, do we care? Should we care? What data would be necessary for us to be convinced one way or another, and what are the barriers to gathering these data? The common exercise then focused in specifically on antibiotics in the water, which was at the same time a narrowing of scope to one class of drug, and an expansion to thinking beyond human impacts on water quality.

Integrating the Module into Your Course

I did the antibiotics in the Mississippi River watershed and I put it in my honors Biological Fate of Drugs course. This was the last thing that I did at the very end of this semester. So it was the final culminating chunk. And where we ended the semester was a conversation of what happens to a drug physically when you take it. So, what barriers does it need to overcome in order to be effective in your body? And it worked really well because we talked about how your liver is in charge of metabolizing the drug, what does that mean, and then we talked about how your body clears the drug. Where does it go? Eventually drugs wear off, that's why you have to take Advil every four to six hours. So, what happens when the drug leaves your body? Where does it go? And we talked about the kidney and how most drug is excreted in urine and it can be excreted unchanged or metabolized and then what happens? And so then we walked into a conversation of, "Well, then it's going to go into the waste water, right?" And what happens then? The (next) specific part was looking at some really interesting papers that show levels of really commonly prescribed drugs when they go into the wastewater treatment facility and when they come out and how you would hopefully expect those numbers to go down, that the wastewater treatment would effectively remove drugs. But there's really interesting cases where the concentration actually increases when it leaves the wastewater. And so we talked about why might that be happening and why are we so bad at removing drugs from waste water? And where does wastewater go? Because even after treatment, we can show that all of these drugs are still in the water. What does that mean? And we talked a little bit about the ecological implications of that, but not too much, we mainly focused on human health. And the course specific exercise was then really sort of a facilitated discussion where the question was just, do we care, right? There are drugs in the water, do we care? Why might we care? Why might we not care? What would it take for us to care? What does this mean from a political standpoint, from a policy standpoint, from a health perspective, do we care? And there were a lot of really differing opinions, which was a really great conversation for the students to have on a lot of different pieces that we brought up over the course of this discussion. Once we had this conversation about, "There are drugs in the water" (and we did focus it on locally), we moved to the common exercise of looking at the Mississippi River watershed more broadly and doing the antibiotics module for that. Some of it I pared down because we covered the topics already. But we only really talked about human waste and drugs in the water, so this expanded it to looking more broadly at use in animals and how that is the bulk of the antibiotics that end up... So we specialized when we moved into the common module to only talk about antibiotics, whereas before we were talking more broadly about drugs.

What Worked Well

I think that the progression worked really well. I felt pretty good about how it was set up in terms of talking about the excretion of drugs broadly. It fit really well into the end of the course. And then moving that into a conversation of, "Okay, now we're leaving the human body. Now we're just going to follow this drug and we're going to look at the data in terms of where does it end up? And maybe it doesn't end up where we think it does." And, "What do we know about how much drug is in the water?" We looked at various EPA reports and WHO estimates and stuff like that. So, the integration on that worked really well, which was the piece that I felt I did not do well the first time around. That piece fit in nicely. I think part of that was the specialization of looking specifically at antibiotics and I think part of it was also just switching it to a different class because before I tried it in Human Biology.

Challenges and How They Were Addressed

So when we got to the common exercise, specifically the Town Hall, but also pieces of the common exercise and the examples used, some parts of that didn't really fit into the course very well. I found that I was needing to do a huge amount of background research to try to figure out some of the data that were presented. I loved the fact that a lot of the material presented in the antibiotics slide deck were primary literature sources, but I found that there wasn't quite enough information in the figures for me to actually understand what they were trying to explain. And so I was Googling the names of Latin things to be like, "Oh, that's grass. Okay, I know what grass is." So that took up more time than I thought it would. I think they (the students) got a little bit of whiplash moving from very detailed human analysis to suddenly thinking about predominantly livestock and how livestock might impact the concentrations in the water. It is a very different frame of reference of thinking just about me to thinking about animals and then a watershed. So that switch was a little confusing for them. And in the Town Hall exercise, I think that some of the roles did not translate very well for them. Again, within the context of the course, which was pretty human specific. One thing that I think that would've improved the Town Hall in retrospect was if I had allowed them to choose their own roles, to define the roles for themselves, and then use that as their stakeholder perspective, because I found that some of the students were really engaged in the roles that they held, whereas others, not so much. You know, my fisheries group, they weren't psyched about. They just really weren't. The NGO group, similarly, not super excited about it. But when we did the stakeholder mapping, they came up with some really interesting smaller stakeholders, but then also bigger stakeholders. We had a portion of the class that were really interested in policy implications. And I think that there would've been a lot more authentic passion and interest in the topics. At first we had defined the roles and then they got to choose those roles as part of the Town Hall exercise. So that is something that I would probably consider doing moving forward.

Student Response to the Module and Activities

I think we talked a lot about how there's no good answer to this question. And we started that conversation when I asked, "Do we care about these drugs in the water? Does it matter? Do we care? And we have no idea if we should care, right?" There's no easy answer to that question. There's just not enough data. And so that was a really common theme of, "Who knows if this is a really complicated problem? And there are a lot of different people who care about it from a lot of different perspectives. And how do we get people to speak the same language and understand each other's concerns and try to arrive at solutions if there are any that people feel comfortable with?" So I think that they understood that. We had some pretty interesting conversations between some groups in the Town Hall where students were proposing some interesting solutions to this problem of antibiotics in the water. And it was interesting that they immediately jumped to solutions oriented thinking. The complexity of the problem, they obviously want to narrow it down really quickly and say, "This is the answer." But they were capable of recognizing the limitations of the solutions that they were coming up with. So, I hope that they understood the complexity, which is really what I was going for. Get them to understand the complexity and then also get them to understand the data problem. How we don't have enough data and we're not going to get it. There's no easy way to get the data that we need to understand if we should care about antibiotics in water.