You can have the best and most effective treatments, but if patients don’t utilize them or don’t utilize them properly, things are not going to turn out as you expect. Thus, the problem of medication adherence is a significant one, though not always fully appreciated for its widespread prevalence and impact on health.
I am not going to address nonadherence to preventive interventions such as physical exams, vaccinations and the like. I address myself solely to medication nonadherence. A patient has a medication prescribed for an indication—is the prescription filled right away? Is the medication taken as prescribed? Is it renewed as needed?
One of the earliest contexts in which this problem played out and in which it was studied was in pediatric acute care: the use of antibiotics in the child with streptococcal pharyngitis (strep throat). While most such infections would probably resolve without antibiotics, the fear of this infection was that untreated strep throat would result in a few percent of children developing the dreaded complication of rheumatic fever, a fairly common condition decades ago. The utilization of antibiotics in this setting has mostly eliminated this condition in our era. A typical recommendation by a pediatrician was penicillin two to four times/day for seven to 10 days. Studies in the mid to late 1950s and early 1960s showed that nonadherence was common. One oft-cited study of children under 6 years of age found that more than 50% were nonadherent by the fourth day and only 20% made it to the 10th day. Older children did worse, and as for adolescents—don’t ask.
I mention this only as an illustration of the breadth and extent of the problem—have we not all dealt with this situation? But it is in the arena of medications for chronic conditions that this issue really becomes paramount. The use of one or more medications for chronic conditions—hypertension, hyperlipidemia, arthritis, osteoporosis/osteopenia, anxiety, depression, mental conditions of one type or another, immunosuppressive therapy, diabetes, migraines, the list is endless—are omnipresent in our society. It is the rare (and fortunate) person over the age of 60 who is not on something.
It is not easy to maintain adherence to medications day in and day out. The statistics are staggering on nonadherence and were highlighted in a review article published in 2005 in the New England Journal of Medicine—my gestalt is that not much has changed since then except for a bit more awareness of the issue. I don’t know exactly how many people fill or don’t fill the prescription in the first place—my estimate is that more than 10-20% are nonadherent out of the gate. Certainly by three months, most of those on a new drug for hypertension or hyperlipidemia have stopped. If you go out somewhat beyond that, like past six months or a year, you are past 50%. For certain conditions, like those in the psychiatric category, the statistics were considerably worse. Osterberg and Blaschke, the authors of the 2005 review, reported that even participants in clinical trials, the most select of the most select, had adherence rates of only 43-78%.
As a physician, it is not easy to know if your patient is adherent. First, you have to think to ask—even if you do ask, the neatly dressed person sitting in front of you, perhaps an educated professional, is going to lie through his/her teeth. Patients don’t want to disappoint their caregivers. My dental hygienist asks me if I have been flossing—I soberly nod my head—she just laughs, rolls her eyes and gives me my bag with a new toothbrush and toothpaste, and my nose gets longer. Surveys of physicians invariably show that doctors think they can tell which patient is or is not adherent—and you wonder how and why professional poker players always win.
In actual studies of nonadherence where pill counting is done, for example where the bottle cap has a sensor that records when the bottle has been opened, it is frequently the case that the bottle goes most of the month without being opened and then is opened three to four days prior to the visit to the physician—and amazingly the pill count is correct.
How do we get around this? For some drugs, like anti-tuberculosis or anti-HIV meds, actual daily observation has been utilized when necessary. Another increasingly popular strategy is to shift from oral to parenteral medications—injectable or intravenous bisphosphonates for osteoporosis are replacing pills. Reduction of the frequency of dosing (once instead of multiple doses per day), reduced co-pays, fewer meds, positive reinforcement. Wherever possible, we should take the choice out of the hands of the individual patient—fluoridation of the water supply as opposed to relying on the individual person to use fluoridated toothpaste or folate supplementation of commercial baked goods so we don’t have to rely on pregnant women to get prenatal vitamin supplements.
These issues have become salient in cancer as the number of oral chemotherapy medications has exploded. In our next article, we explore nonadherence in cancer in “Thoughts on Cancer.”
Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: [email protected].
This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.
