Cell Phone Photos May Make Adherence a Snap

Simple, low-cost method may help boost adherence in a wide variety of patient populations

Deborah Brauser

August 25, 2011

August 25, 2011 — Using a cell phone to snap and then send photos of each dose of medication right before taking it may improve treatment adherence in patients with methamphetamine addiction, new research shows. This simple, cost-effective method also may be applicable in other patient populations in which adherence is an issue.

In a small pilot study of 20 methamphetamine-dependent patients prescribed either modafinil or placebo, investigators found that cell phone pictures provided "more accurate time measures and more frequent adherence assessment" than either pill counts or medication event monitory system lids (MEMS Caps).

"Given the ubiquity of cellular telephone use, and the relative ease of this adherence measurement method, we believe it is a useful and cost-effective approach," the researchers note.

"Medication adherence is a serious problem. This relatively simple technique is something any clinician could put into practice right now for almost any patient," lead author Gantt Galloway, PharmD, senior scientist at the Addiction and Pharmacology Research Laboratory at St. Luke's Hospital in San Francisco, California, told Medscape Medical News.

Dr. Gantt Galloway

Although both cell photos and bottles with MEMS Caps were useful for collecting adherence data, the photo method underestimated adherence and the MEMS bottle method overestimated it compared with pill count.

"Still, this new method may serve as another way of stressing the importance of medication taking," added Dr. Galloway.

The study is published in the September issue of the Journal of Addiction Medicine.

No Gold Standard

According to the researchers, individuals are often reluctant to admit to medication nonadherence, with self-report overestimations reaching as high as 300%.

"Although many methods of measuring adherence have been investigated, there is as yet no 'gold standard,' " the authors write.

"Traditional counts of dosage units do not provide information on when capsules are taken or even if they were taken at all."

In contrast, MEMS Caps, which uses bottle caps equipped with microchips to record each bottle opening, is an expensive method of tracking adherence and does not differentiate between opening the bottle to take the prescribed dose and just opening it to check how many capsules remain.

"MEMS Caps have lots of advantages, but you have to pay $100 or so to purchase each one, you need the software to read them, and it's just a little cumbersome," said Dr. Galloway.

"However, these days, more and more people have cell phones that can take photographs."

Time Stamped

The 20 methamphetamine-addicted patients enrolled in this study (55% men; mean age, 40.9 years) were issued cell phones and a week's worth of either modafinil or placebo capsules in MEMS Cap–equipped bottles.

They were told to take 1 capsule per day for 8 weeks and to record their adherence by taking a photo before ingestion and then immediately emailing it to a specified account. A time stamp was included on every picture.

During weekly inpatient visits, pill counts from returned bottles were also recorded for each participant and compared with weekly MEMS and photograph estimates of adherence.

Payment was given to each subject for participation, as well as for each capsule photograph sent ($3 per picture), for each MEMS Cap bottle returned ($20 per return), and for the undamaged cell phone at the end of the trial ($50).

Results showed an overall adherence estimate of 94.9% (standard deviation [SD], 13.5%) by pill count, 93.6% (SD, 15.0%) by MEMS, and 76.9% (SD, 14.6%) by cell photo.

"Weekly photographs and MEMS agreed with weekly capsule counts with similar frequency" (39% vs 37%, respectively; odds ratio [OR], 1.11), report the investigators.

However, "when weekly measures disagreed with capsule count, MEMS overestimated adherence more than photographs (39% vs 14%; OR, 3.88; P < .001), and photographs underestimated adherence more than MEMS (49% vs 22%; OR, 3.48; P < .001)."

Cause for Concern

The researchers note that the underestimation may be a result of photographs not being sent in, even though the participants would receive payment to do so.

"In the clinic, low estimates may increase attention to adherence, but spuriously high estimates may lead to false confidence by the clinician; therefore under-reporting is preferable," they write.

"Some social desirability issues, where people may want to present as having taken their medications, can lead to overestimation of adherence for pill counts also," added Dr. Galloway.

Although the participants who dosed at about the same time each day were significantly more likely to adhere to their prescribed medication (P = .027), neither length of methamphetamine use nor cravings were associated with compliance.

The investigators note that some discrepancies in the timestamp recordings by MEMS were detected, with 62% of the photos showing timestamps earlier than the recorded MEMS timestamps.

"Because timestamps are a primary benefit of MEMS, this discrepancy is cause for concern," write the researchers.

Privacy Concerns

They also cite privacy concerns as a possible limitation of the cell phone photo method.

"Despite data encryption used by phone carriers, it is possible to intercept or monitor data sent by cellular telephone and potentially even track phone location."

Still, "innovative uses of cell phones offer researchers and clinicians new ways to improve clinical trials and practice," they add.

When asked whether he thought adherence might still be high with the photos without any monetary incentives, Dr. Galloway said, "That's a good question and would need to be tested."

He added that studies with much larger numbers of participants are also needed.

"For now, this provides another tool to assess adherence that is readily available to clinicians."

Outside Comments

"I thought this was an interesting and somewhat ground-breaking study because it used new technologies to measure medication adherence," James L. Sorensen, PhD, professor of psychiatry at the University of California-San Francisco and from the San Francisco General Hospital, told Medscape Medical News.

Dr. James Sorensen

"I think it opens up some possibilities both for research and for clinical treatment. And it just seems like a good idea," added Dr. Sorensen, who was not involved with this study.

He said that medication adherence is important for all individuals, and especially for those who have drug problems. "As mentioned, there is no gold standard measure right now. Yet we need good ways of understanding whether or not these patients are taking the medication we've prescribed them."

Dr. Sorensen said this becomes even more important for regimens that require "a lot" of discipline.

"Until recently, HIV medications were being given with complicated dosing schedules and prescribers had no idea whether the regimen was being followed correctly or not. Cell phones may give a relatively sensitive measure, which I think is a good thing &emdash; as long as both patients and clinicians understand the technology."

However, he voiced a few apprehensions, including the privacy concerns noted by the study authors.

"I work with substance abusers and they are not real trusting of the medical establishment. So these people may be afraid they could be tracked in some way, or information could be downloaded later, or you might get pictures of somebody doing something illegal. There is potential for abuse in any measurement and this has its share," said Dr. Sorensen.

"Still, the advantage is very clear: you could be gathering information about adherence in the field without having to go out and live with the patient."

Dr. Sorensen also noted that although the study participants were reimbursed for sending in the photos on a regular basis and turning in their MEMS Caps, he is not sure how big an impact the rewarding had on the results.

"As pointed out in the article, that's an empirical question and certainly should be studied. In our own study, we used incentives to reinforce [methadone patients] opening HIV medication bottles and used 3 different adherence measures, all of which were improved by providing incentive. So that definitely made a difference."

"Overall, I think this new method a very good idea and a very creative response to a problem. I look forward to seeing it followed up in future research as it may end up being a very valuable tool," concluded Dr. Sorensen.

The study was supported by a grant from the National Institute on Drug Abuse. The study authors and Dr. Sorenson have disclosed no relevant financial relationships.

J Addict Med. 2011;5:170-174. Abstract

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