Pharmaceuticals have emerged as a major group of environmental contaminants over the past decade but relatively little is known about their occurrence in freshwaters compared to other pollutants. We present a global-scale analysis of the presence of 203 pharmaceuticals across 41 countries and show that contamination is extensive due to widespread consumption and subsequent disposal to rivers. There are clear regional biases in current understanding with little work outside North America, Europe, and China, and no work within Africa. Within individual countries, research is biased around a small number of populated provinces/states and the majority of research effort has focused upon just 14 compounds. Most research has adopted sampling techniques that are unlikely to provide reliable and representative data. This analysis highlights locations where concentrations of antibiotics, cardiovascular drugs, painkillers, contrast media, and antiepileptic drugs have been recorded well above thresholds known to cause toxic effects in aquatic biota. Studies of pharmaceutical occurrence and effects need to be seen as a global research priority due to increasing consumption, particularly among societies with aging populations. Researchers in all fields of environmental management need to work together more effectively to identify high risk compounds, improve the reliability and coverage of future monitoring studies, and develop new mitigation measures.