Medication Nonadherence: Finding Solutions to a Costly Medical Problem

Harold Gottlieb, PhD

Disclosures
In This Article

Improving Adherence

Patients should be encouraged to indicate to their physicians verbally or in writing that they understand medication requirements. Physicians should be aware that patients are more likely to adhere to medication regimens when they are convinced that the medication they are taking is clearly linked to future health and wellness and when they are made an active participant in the decision-making process regarding the medications. Most busy physicians fail to reserve time for quality interaction with their patients and, therefore, often fail to consider adherence issues. However, failure to tackle adherence issues early may cost the physician more time and energy later.

Some physicians talk rapidly and disregard patient understanding. And many patients are not always good listeners, in part because of a number of distracting internal and external psychological factors; they are in a strange environment, and they more than likely are distressed, anxious, frightened, or in pain. Thus, to promote medication adherence, patients need to be instructed properly, asked to participate in the decision-making process, and helped to understand the benefits of taking their medications as well as the risks of not taking them. Patients must be told in a simple and clear way how to take their medications. The patient must be able to read and understand, as well as comprehend and translate what he/she understands into actions that conform to the physician's instructions.

Some patients have poor memory and concentration skills, and they seem to quickly forget over half of the physician's instructions. In fact, they are more likely to remember their diagnosis than their prescribed therapy.[16] The provider must speak briefly and clearly, emphasize the information necessary for compliance early in the communication, and then repeat the same information both orally and in writing. We cannot assume that patients understand even simple language. Terms common to the practitioner, such as "follow-up" and "workup," may very well require explanation or substitution.[17]

In a study of patient interpretation of written prescription instructions, researchers found that 25% of subjects interpreted the phrase "every 6 hours" as meaning "3 times a day" (since they sleep at night). "As needed for water retention" was thought to mean that the pills would be used to cause water retention.[18] Full clarification of medical terms is strongly encouraged, and more structured follow-up sessions may be necessary to determine whether patients understood the information and instructions.

The physician should seek the support of pharmacists, nurses, and the patient's family in reinforcing instructions. Patients must be given clear instructions about when to return for medication-adjustment visits and should be alerted to the possibility that they may have to bring all of their medications to each visit for adherence assessment. Above all, patients must be made aware of their adherence and compliance responsibility at the outset.

Patient motivation must be evaluated to determine the likelihood of medication adherence. While many patients appear motivated, they actually may be in a precommitment phase in the decision-making process; that is, while patients may wish to take their medications, they may not be ready to comply with all aspects of the medication regimen.

Patients can be issued a medication adherence "contract" at the initiation of treatment. The contract should include a simple and clearly written set of instructions that describe the medications; important facts about the medications, including side effects and interaction with other medications; and information as to the purpose of the medications and the consequences of not taking them as prescribed.

The contract needs to include when and how medication readjustments will occur and when and how prescriptions will be refilled. A schedule of medication intake should also be included -- that is, time contingency or pain contingency instructions plus dose frequency and length of time the patient is expected to take the medications.

A behavioral contract can include information about frequency of expected office visits; how to contact the physician in an emergency; what to do when an emergency occurs; and, most important, a relapse prevention plan. The patient should also be instructed to never change his medication regimen without the full consent of the treating physician.

The medication adherence contract can include information about community support groups and other resources that might be available to promote patient adherence to medication regimens. Moreover, a copy of the behavioral contract can be made in triplicate. One copy can be given to the physician, one to the patient or patient's family member, and one to any other designated person, such as a close friend or coworker.

The contract can be signed and treated as if it were a legally binding document. For those who have difficulty reading, the contract can be taped, and the patient can be encouraged to listen periodically to the recorded message. A designated caregiver can be assigned to those patients who exhibit special needs, with the caregiver reading the contract to the patient and helping him to adhere to its terms.

Often, a particular therapy cannot be modified; but whenever possible, results from the many studies examining the relationship between various characteristics of the treatment plan itself and the likelihood of patient cooperation should be examined for medication adherence strategies. In general, compliance rates can be increased by merely altering such components of the treatment regimen as complexity of treatment, duration of treatment, requirements for lifestyle change, and even the cost of the regimen itself.[19,20,21] Once again, research findings have led many reviewers to suggest a multiplicity of tactics to improve compliance. For instance, one approach could be to reduce the number of daily administrations and/or different medications by using, if clinically acceptable, fewer pills by issuing larger doses and even larger pills that are pharmacologically designed to be taken once a day. Moreover, single-tablet, combined medications can also be recommended to reduce the overall complexity of the total regimen.

There are a variety of other strategies that can help promote medication adherence (Table 1). One strategy involves linking a medication schedule with other daily activities. Patients can be told, for example, to place their medication schedule next to their toothbrush as a mnemonic strategy in that they would be reminded of their medication schedule every time they brushed their teeth. Patient reminders can be linked to other daily routines that match the medication intervals related to the patient's recommended medication dose and the frequency and duration of the medication schedule.

The patient's family can help ensure medication compliance. Routine automated phone call reminders can also serve to periodically remind the patient of the proper medication regimen. Some health care workers give lectures, which can include audiovisual aids, and distribute educational materials to patients during evening classes held in the physician's office. The classes serve as an opportunity to inform the patient about the disease and how best to handle it, including the importance of medication adherence.

Drug manufacturers can also provide once-a-day medications, when feasible, and more user-friendly dosage forms. They can offer products that have simpler regimens, rather than multiple-dose regimens, and they can discourage awkward packaging of medications by favoring single-unit packaging. The community-based pharmacist can help implement the medication adherence strategy by providing periodic telephone calls to remind patients to take their medications.

The above suggestions are just some of the ways patient noncompliance to medication regimens can be remedied and are by no means meant to be an exhaustive list. Clearly, not all patients require an extensive behavioral contract or a medication-adherence compliance plan, but all patients should be provided with at least some relevant, behaviorally oriented set of instructions. In the final analysis, compliance will never happen unless the health care practitioner who treats the patient enforces it.

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