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No Magic Pill to Cure Poor Medication Adherence

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You are sick with something-or-other and your doctor writes you a prescription for a medication.  She briefly tells you what it's for and how to take it.  You go to the pharmacy, pick up the medication, go home and follow the instructions, right?  I mean, how hard could it be?

Pretty hard, it appears.  Between 20 percent to 80 percent of us differing by disease and drug don't seem to be able to do it.There are, of course, many reasons we aren't.  Drugs are sometimes too pricey, so we don't fill the prescription. Or we buy them and then apply our ingenuity to making them last longer by splitting pills and otherwise experimenting with the dosage.'

Some drugs have to be taken at specific times or under specific conditions, posing little challenge when you are taking only one.  But it can be devilishly difficult to coordinate the green pill half an hour before breakfast, the yellow ones on an empty stomach four times a day and the orange one with a snack between meals. It's complicated; we don't understand.  We're busy; we forget. We're sick; it's confusing.

Some drugs produce uncomfortable side effects while others set off an allergic reaction. Every single day, we have to decide if the promised outcomes are worth the discomfort.

Kate Lorig, the developer of the Chronic Disease Self-Management Program, has listened to thousands of people talk about the challenges they face in taking their medications as prescribed. One of the reasons that folks do not take their meds is that they think they are not doing anything, Lorig says. 'This is especially true of medications that replace something that you no longer produce like thyroxin or medications for chronic conditions that help you get worse more slowly. The trajectory of a disease is not something one can usually sense, and people start feeling that their drugs are not making them better. Another problem is that people expect drugs to work at once like aspirin and antibiotics. Many drugs take days, weeks or even months for people to feel better. They lose patience.

Depression also plays a significant role: a meta-analysis published last week found that people with chronic conditions and who also were depressed were 1.76 times more likely to be non-adherent compared to people with chronic conditions who were not depressed.  This finding is particularly important because while depression is common in the general population, it is much higher in those over 65, who are also more likely to have additional chronic conditions, most of which require medications to manage and treat.

And then there are people like me who physically struggle to take pills.  I have a lazy swallowing reflex as the result of radiation to my throat, and I frequently gag on even small tablets.  And so I approach every single pill I take with a vivid fear of choking to death on it.  Good excuse for not following my chemotherapy regimen, no?

Add to this list of common explanations for why we don't take our drugs as directed the media messages and cultural tropes that feed our ambivalence: "Drugs are dangerous!"  What looks safe now may turn out to hurt you in the long run'remember Vioxx?''  Ask your doctor about this drug that will make you feel calm and confident about a) your sexuality; b) your bathroom needs; c) your interpersonal relations; d) your eyelashes. Then, compare my friend in excruciating pain from a spinal tumor who refuses strong pain medication because she doesn't want to get addicted to it with the teenagers all over the country who seek out that same medication to ease the anxiety of growing up.

This is a complicated picture.

So it is no wonder that an encyclopedic Cochrane review that evaluated interventions to improve medication adherence found that 'No one type of strategy improved medication use outcomes across all diseases, populations or settings, or for all outcomes.''  Think about it: What 10-page pamphlet, 10-minute counseling session or $10-off coupon could reliably help all of us overcome the barriers described above?

The review found that some strategies show modest promise: self-monitoring, greater pharmacist involvement, simplified dosing. Other strategies produce fewer (although some inconsistent) effects: reminders, skills training, financial incentives, use of lay health workers.  But research on medication adherence is not well organized across diseases, populations and settings, the review said, and there are many gaps in the assembled evidence on medicines use strategies, such as those focusing on children, young people or carers, or those for people with more than one coexisting health problem.

Unfortunately, this means that policy makers and health professionals have little guidance about what can be done to help us improve the way we use medications.

This is simply not good enough.

Ninety percent of American seniors and 58 percent of non-elderly adults use a prescription medication on a regular basis.  These numbers will increase as personalized medicine goes mainstream, offering us the opportunity to ingest exquisitely tailored medications that can counteract our genetic flaws to extend our lives.

Think about it: Hundreds of millions of dollars worth of research is translated into a drug that costs millions of dollars to produce, which in turn cost hundreds of dollars for a clinician to prescribe and tens of dollars for our health insurance to pay for -- but the potential of that drug to alter the course of a disease depends on the actions of an individual: you, me, my friend with dementia, your aging neighbor, your grandchild with type 1 diabetes.  If we don't take the drugs as directed, we don't realize their benefit.

The nation has poured public and private money into basic research and drug development and invested heavily in training health care providers.  But as the Cochrane review demonstrates, the research that would strengthen the critical link between all those investments and the individuals who are ultimately responsible for ensuring that it has an effect is limping along: equivocal, uneven and irrelevant to many of those who stand to gain the most from the drugs available to them.  Meanwhile, such system-level remedies such as simple uniform medication labeling are lost in a morass of self-interested wrangling.

If the success of modern medicine to improve health relies so heavily on our actions, it's time for more concerted, strategic approaches to reducing the significant barriers to us taking both the medicine and actions as recommended.

The systematic review found that there is no "magic pill" no single intervention that will solve the adherence problem.  Why should there be?  We know from other efforts to change complex behaviors, such as cigarette smoking, that it is only when a variety of approaches support, encourage, prompt and reward the new behaviors over time that significant numbers of people will adopt them.  Improving adherence will require a concerted effort by the pharmaceutical industry, health plans, pharmacists and clinicians to step up implementation of even mildly promising interventions to make it easier to follow recommendations.

The impetus for an increased investment to support medication adherence may, oddly enough, come from clinicians themselves.  With the advent of pay-for-performance and other incentives that link provider reimbursement to patient outcomes, we are no longer the only beneficiaries of the effective use of our drugs. It is possible that this nudge will spark productive interactions between clinicians and patients about what and how the drugs they prescribe for us can be best used to help us prevent complications, slow the progress of our diseases and ease our suffering.

More Blog Posts by Jessie Gruman

author bio

Jessie C. Gruman, PhD, was founder and president of the Center for Advancing Health from 1992 until her death in July 2014. Her experiences as a patient — having been diagnosed with five life-threatening illnesses — informed her perspective as an author, advocate and lead contributor to the Prepared Patient Blog. Her book, AfterShock, helps patients and caregivers navigate their way through the health care system following a serious or life-threatening diagnosis. The free app, AfterShock: Facing a Serious Diagnosis, offers a pocket guide based on the book. | More about Jessie Gruman


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dirk says
May 20, 2011 at 10:13 AM

It would certainly be helpful for clinicians to discuss with (starting by listening to) patients their (the pt's) understandings of what medications are and what they do. Certainly one of the major problems/gaps here is the lack of scientific understanding by many patients about drug/disease processes, but getting people (especially frightened/stressed people) beyond their folk-psychological understandings of causality and such may be beyond the limits of an office room chat.

Grand Rounds Vol. 7 No. 35 | Medgadget says
May 24, 2011 at 10:07 AM

[...] week’s Grand Rounds host, Jessie Gruman of Prepared Patient Forum, takes a thoughtful look at medication adherence from the patient’s perspective. “Think about it: Hundreds of millions of dollars worth [...]

Grand Rounds Vol. 7 No. 35 | Medical Equipment says
May 27, 2011 at 3:54 AM

[...] week’s Grand Rounds host, Jessie Gruman of Prepared Patient Forum, takes a thoughtful look at medication adherence from the patient’s perspective. “Think about it: Hundreds of millions of dollars worth [...]

ApothecaryMom says
June 15, 2011 at 11:49 AM

Great, in-depth blog article Jessie. There are many reasons for non-compliance but there are some simple, easy solutions. If you have trouble swallowing--like you mentioned--try using a pill cutter or crusher so the pills are smaller and easier to swallow. I use the Ezy Cut Tablet Cutter for my familyâ??s medications. It cuts all shapes of pills and has adjustable arms to center your pill to make it easier to split. It also has a finger guard to prevent cuts. There is a YouTube video on it you can Google. -Susan

A FICO Score For Medication Compliance? - Better Health says
July 13, 2011 at 10:02 AM

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