A major pharmaceutical company has been running a radio advertising campaign in the Detroit, Mich., market encouraging people to improve their medication taking. The ad's tag line is, “It only takes a minute to take your meds.” A well-intentioned message, certainly, but one that understates the complexity of a patient's decision whether to take or not take a prescribed medication. Persistence in taking medications, especially on a long-term basis, is difficult, and medication-taking behaviors of patients are not routinely assessed by their caregivers. The data documenting medication nonadherence are stunning. Only 50–60% of patients take medications for their chronic diseases as prescribed,1 two-thirds of Americans fail to take any or all of their prescription medicines, 22% of Americans take less of the medication than is stated on their prescription label, and 12% don't get their prescriptions filled at all.2 A recent study3 observed that only 43, 29, and 52% of patients with diabetes have achieved recommended targets for hemoglobin A1c, blood pressure, and LDL cholesterol,respectively, despite the availability of multiple medications proven to be highly effective in treating these conditions.
Given this state of affairs, it is not surprising that health care providers are frustrated. Unfortunately, that frustration often translates to labeling patients as “noncompliant” or “nonadherent.”Not only are patients “noncompliant” with their meds, they are“noncompliant” with their diets, exercise programs, plans to lose weight, efforts to stop smoking, and the list goes on. Steiner and Earnest,1 of the University of Colorado Health Sciences Center observed the following:
Terms like compliance and adherence are too facile to describe these complex behaviors. They should be replaced with a language that is less succinct but richer in its description and analysis of human behavior. We must assess what our patients are doing and understand why they do it if we wish to help them change. In this effort, our language is as powerful a tool as the medications we prescribe.1
Medication taking is a behavior, and like all human behaviors, it is subject to many influences, but ultimately it is subject to the individual patient's choice. In 2003, the Boston Consulting Group published results of a patient survey, “The Hidden Epidemic: Finding a Cure for Unfilled Prescriptions and Missed Doses.”4 One of the survey findings was that most patients who fail to persist in medication taking do not simply forget to take their medications, but rather actively choose to disregard their provider's directions. Among the reasons for not taking medications were unacceptable side effects, cost of medications, decisions that the medication was not needed, and difficulties in filling the prescription.
There is no simple fix for a problem as complex as medication nonadherence. But at the heart of the issue is the level of rapport and communication between providers and patients. The issue is not simply whether clinicians ask about adherence, but how they ask.5 Consider this patient's description of a recent encounter with her physician:
I absolutely felt terrible each time I took this medicine, so I stopped taking it. When I went in for my next visit, I explained to the doctor that I didn't take it. So, he raised the dosage because he said it wasn't working. I'm like, `Are you listening to me? I just told you that I'm not taking it,so....'” (M. Pladevall, unpublished observations)
However, effective communication takes time, patience, and experimentation with techniques that may not always work. The complexity of drug therapy in chronic disease, combined with pressures on providers to see more patients in less time, appears to conspire against extended assessments of medication-taking behaviors.
So, is there an answer to this dilemma? Breaking down a complex challenge such as medication nonadherence into smaller, more manageable tasks is perhaps one place to start. Using open-ended questions allows patients to provide insight into issues affecting their ambivalence about medication taking. Such questions may include, “How do you manage to take your medications on a consistent basis?” or, “What gets in the way of taking your medications regularly?” Acknowledging the difficulty of juggling medication taking with other disease self-management behaviors or with other daily priorities may provide relief for patients to be more open about issues that interfere with their taking medications consistently. Furthermore, the burden of improving medication taking should not fall on providers alone. A framework has been suggested that views patient medication adherence as a systems issue that involves nurses, pharmacists, dietitians, case managers,community health workers, and others in a coordinated fashion to deliver a consistent message to patients.6 It is an effort that will require different approaches than those that have been used until now, but could we do any worse than we currently are?
Roger P. Austin, MS, RPh, CDE, is a clinical pharmacist with the Henry Ford Health System in Sterling Heights, Mich., and an associate editor ofDiabetes Spectrum.
