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The
Real Drug Problem: Forgetting to Take Them As
Many as Half of Patients Fail to Follow Their Regimen; a Pillbox That Can
Nag By
Amy Dockser Marcus, The Wall Street Journal It has become one of the
most perplexing problems in medicine: Only about half of the people on
prescription drugs actually
take them. Much of the national
debate focuses on how to help more people afford costly medicines, but
that in many ways has masked the increasingly urgent problem of getting
patients to take medicine once they get it. The consequences of
non-adherence, as many doctors refer to it, are significant. Failure to
take prescribed drugs
contributes to everything from avoidable emergency-room admissions to AIDS
deaths; it can also undermine efforts to manage chronic conditions, such
as asthma, diabetes, high blood pressure and depression. Earlier this year, the
World Health Organization reported that only around 50% of people
typically follow their doctors' orders when it comes to taking
prescription drugs -- and
the rates are lower for certain medical conditions. Only 43% of patients
take their medicine as prescribed to treat acute asthma. Between 40% and
70% follow the doctor's orders for depression medication. Just 51% of
patients take the prescribed doses of high blood pressure medicine. The phenomenon is a major reason that the promising
results of drugs in
clinical trials often aren't matched when the drugs
are in the hands of other patients. Trials of antiretroviral therapies,
for instance, have proved effective in suppressing the AIDS virus in as
many as 95% of participating patients. But in the routine of daily life --
when patients are less vigilant about following doctors' orders -- the
reported rates of suppression drop to the 40%-50% range. Doctors believe
the discrepancy is one important reason why so many people still continue
to die from AIDS. The issue of why people don't take their medicine, even
when they need it to prolong or save their lives, belies simple
explanations or demographics. Rich, highly educated people are just as
likely not to take their medicine as poor or less-educated people. Some of
it is human nature, an inner rebellious voice that resists the doctor's
orders. Many patients mean to take their pills but don't write down what
the doctor says and end up not following the instructions properly. Others
forget, particularly when they have to do it more than twice a day. There
is also the growing expense, even for people with insurance, as many
insurers raise co-payments on drugs . But the major reason appears to be a fear of side
effects. People don't like the way they feel when they take many drugs , so they simply stop taking them. A Lifelong Burden The problem appears to be getting worse. Medications are
getting better and are more effective in treating a wider range of
diseases, but many need to be taken for long periods, even a lifetime.
Many diseases for which patients end up taking medicine for years on end
-- such as high blood pressure and high cholesterol -- often don't have
overt symptoms, making patients even less likely to take medicine
faithfully. In addition, more doctors are prescribing medicine for
prevention, giving patients less incentive to follow instructions. "There is a fundamental change taking place in the
way we prescribe medicine," says Cynthia Rand, a professor of
medicine at Johns Hopkins School of Medicine in Physicians, insurers and the federal government are
beginning to address this. The National Institutes of Health now has over
35 trials under way studying ways to improve patient adherence in taking
medication for a range of conditions, including depression and other
psychiatric disorders. A second annual conference devoted exclusively to
improving adherence to HIV therapies is taking place later this year in Doctors' offices are experimenting with voice-recognition
software that places phone calls, sometimes as many as three times a day,
reminding patients to take their pills. Some patients now use smart
pillboxes with electronic devises that beep when it's time to take their
medicine. Kaiser Permanente, a managed-care organization with eight
million members, has its pharmacy analyze refill rates on asthma
medications. It then alerts doctors when patients appear to be refilling
medication that gives immediate relief to acute attacks more than they are
refilling the long-term medication to prevent attacks in the first place.
Kaiser has also expanded a program that trains doctors and nurses to
negotiate with patients about their motivations for taking medicine and
find out what the patient is willing to do. "The idea is the physician's job isn't just to write
the prescription," says David S. Sobel, director of patient education
for Kaiser in The success of such efforts is considered critical to
gain control of the national health bill. One study published early this
year reviewed the wide variety of interventions being used to try to get
people to take their medicine and determined that public-health dollars
would be more effective if spent on finding better ways to get patients to
actually take their medicine rather than on improvements in the medical
treatments themselves. A Cash Incentive Fails But to date, efforts to get people to change their
behavior haven't fared well. One study trying to improve adherence in
adolescents with diabetes even included a $100 incentive for attending
diabetes education sessions. More teens attended the sessions, but it
didn't improve their records taking the medication. Many doctors say they
now tailor the approach to an individual's needs, calling patients who
miss doctors' appointments, mailing information about their medications,
following up with e-mails, whatever strategy seems to work with a
particular person. Often patients don't discuss the problem with their
doctor. "It's like when the dentist asks you if you've been flossing
your teeth twice a day," says Ms. Rand of Johns Hopkins. "People
lie because they know what the right thing to do is and they are
embarrassed that they are not doing it." But Kaiser's Dr. Sobel says people who are having
problems taking their medicine should discuss it with their doctors
because sometimes adjustments can be made. If someone is taking five
medications, he says, sometimes one or more can be eliminated. In other
cases, a doctor can simplify the drug
regimen so that a patient needs to take several medicines only once or
twice a day rather than three or more times. 'Oops, I'll Take Them Tomorrow' Joanne Kruidenier, a 70-year-old emphysema and heart
patient at the National Jewish Medical and "He would start to tell me and I'd tune him
out," she says. "I was overwhelmed." She also didn't like admitting that she has a chronic
condition and will require drugs
for the rest of her life. "Sometimes I forget to put them in my
purse," she says. "I'd dress for the day, leave the house,
realize I forgot them and say, 'Oops, well I'll just take them tomorrow.' " Her behavior didn't start to change until recently, she
says, when a nurse shared her own experience of not taking her diabetes
medicine -- and the kidney failure that arose as a result. Her story made the difference for Ms. Kruidenier. But she concedes she still has room for improvement. "I'm doing much better now, but it's still not 100%," she says. "I never realized how hard it was going to be to take my medicine." Copyright
© 2002 Global Action on Aging |
