An adult living with type 2 diabetes often requires around 60 units of insulin daily, resulting in the use and disposal of 75 plastic pens annually.1 Northern Sydney Local Health District (NSLHD) implemented a project to switch to reusable pens, as part of its mission to to reduce healthcare-associated waste and reach a target of net zero emissions by 2035.
In 2021, over 1.3 million Australians (1 in 20) were living with diabetes, with 5.3% of all prescriptions dispensed (more than 16.5 million) identified as diabetes medicines.2.3 An alternative to disposable plastic pens, is the use of metal pens. Metal insulin pens have a shelf-life of five years, and the glass insulin vials that accompany these are subsidised for consumers by the Pharmaceutical Benefits Scheme (PBS). Replacing plastic insulin pens with metal reusable pens within NSLHD could potentially save over 1.25 million disposable pens per year, reducing plastic waste by over 230 tonnes annually.
Addressing attitudes to reusable pens
The DISPENSE Study aimed to address environmental concerns surrounding insulin delivery consumables for people living with diabetes. The project team surveyed prescribers, diabetes educators and consumers on their attitudes towards the use and prescription of insulin pens, as well as the barriers facing uptake and prescription of metal pens. They also developed prospective semi-quantitative, qualitative structured questionnaires and delivered these using REDCap. The project team obtained ethics and governance approval to disseminate questionnaires at Royal North Shore Hospital and through the Endocrine Society of Australia and the Australian Diabetes Society.
Practitioner experience a barrier to prescribing reusable pens
The project team received responses from 72 health practitioners who prescribe insulin pens, 9 diabetes educators and 22 consumers. Despite prescribers indicating concern about the impact of medical waste on the environment, 81% stated they prescribe single-use pens more frequently than reusable. Access to metal pens appeared to be difficult, with less than half (47%) indicating they had a ready supply available.
Prescribers with less than five years’ experience felt less confident and knowledgeable about prescribing reusable pens than those with more than 20 years’ experience. They were also less likely to discuss pen options with patients and teach them how to self-inject. Most diabetes educators reported it was simpler and more time-efficient to teach people to use disposable plastic pens, but the majority agreed most patients can readily manage metal insulin pens, once shown. Diabetes educators also agreed that ‘smart’ pens that record insulin dose and time administered would be useful for many individuals.
Consumers shared concerns regarding the environmental impact of diabetes supplies, and those who use metal insulin pens confirmed they would always prefer these over plastic pens.
Organic shift away from using disposable plastic insulin pens
The project team initially planned the implementation of a multi-faceted strategy focusing on accessibility and education, involving:
- awareness campaigns
- increased availability of reusable insulin pens
- endorsed, educator-led training material targeting early career endocrinologists.
Since undertaking this project a shift has already occurred away from disposable plastic insulin pens for two insulin types in Australia, coincinding with changes in global availability of insulin pens and changes in PBS subsidies. As part of these changes, NSLHD is now using metal pens in hospital wards for one common insulin type.
Beyond insulin, other injectable medications are now increasingly used for both type 2 diabetes and for weight loss. Advocacy work will be important to pressure pharmaceutical companies to avoid using plastic pens for these medications.
This project was part of the NSLHD Net Zero Leads Program.
References
- Yeap BB. Type 2 diabetes mellitus--guidelines for initiating insulin therapy. Aust Fam Physician. 2007;36(7):549-553.
- Australian Institute of Health and Welfare. Diabetes: Australian facts, All diabetes. Sydney; 2024. [cited Jul 2024].
- Australian Institute of Health and Welfare. Diabetes: Australian facts, Medicine use. Sydney; 2024. [cited Jul 2024].
