Why the drugs don’t work: non-adherence to medication
Understanding and breaking down the practical and psychological barriers to taking medicine could boost global health and save billions of dollars
Perhaps foolishly, I thought this time would be different.
I again wrapped the blood pressure cuff around my patient’s arm, as I’d done many times before. I stared at the dial, coaxing it to rest somewhere closer to normal, as if by mental force I could produce a different result. Still high.
Last month, I’d increased both of his blood pressure medications, but clearly it wasn’t enough. My mind, as it does when confronting stubborn hypertension, drifted to a dismal daydream: years of high blood pressure causing his kidneys to shut down, his heart growing thicker and weaker with every pump. A blood clot shoots toward his brain, leaving him unable to speak or move.
“Let’s try another med,” I say.
“Okay,” he replies. “But first I want to try really taking these and see what happens.”
I stopped. In my rush, I hadn’t asked how, when or even whether he had taken his medications.
Medication nonadherence is not a new problem. Ancient Greek physician Hippocrates urged physicians to “keep watch on patients … for through not taking disagreeable drinks, purgative or other, they sometimes die.” The late C. Everett Koop, a US surgeon general in the 1980s, was more direct: “Drugs don’t work in patients who don’t take them.” The World Health Organisation has noted that better medication adherence could have a “far greater impact on the health of the population than any improvement in specific medical treatments.”
Despite widespread recognition of this problem, medication nonadherence remains tenacious, costly and dangerous. Nearly half of patients with chronic illnesses don’t take their medications as prescribed, even after major medical events such as heart attacks and strokes. A study published in May, 2016, recruited 2,445 subjects in Hong Kong with an average age of 65.3 years. It found that 46.6 per cent of hypertensive patients had poor medication adherence. In the US alone, failure to take medications contributes to more than 125,000 deaths and costs between US$100 billion and US$300 billion every year, according to the Centres for Disease Control and Prevention. Medication nonadherence has profound health and economic consequences, but it’s a problem often hidden in plain sight: We don’t always know – or even ask – whether patients are taking their medications.
Why haven’t we made progress?
In part, it’s because medication nonadherence is not one problem, it’s dozens of problems. There are many reasons, practical and psychological, why people don’t or can’t take their medications. These reasons vary by disease, treatment and individual – and without deeper exploration of the barriers, we won’t get closer to the solutions.
Some challenges are logistical: forgetfulness, inconvenience, cost. Research suggests that simply forgetting to take medications is a leading cause of nonadherence and is exacerbated by the inconvenience of some treatment regimens. The likelihood of taking medications falls when patients have to take them more frequently: nearly 80 per cent of patients regularly take medications when there is one dose per day, but only half do so when it’s four times a day. One study found that over three months, the average patient with cardiovascular disease makes five pharmacy visits to fill 11 prescriptions for six different medications. For sicker patients, the situation is worse: They make 11 pharmacy visits to fill 23 prescriptions for 12 separate medications written by four different doctors. With numbers like that, I’d be more surprised if patients took their medications than if they didn’t.
The cost of drugs is another major factor. People are less likely to take their medications when they have to pay more for them. But even if medications were free, it’s not clear we’d solve the problem: One study found that among patients who didn’t have to pay anything for medications, rates of nonadherence were still about 40 per cent.
These practical barriers, while significant, are more straightforward than deeper psychological ones.
For many patients, taking medicine to stay healthy reinforces the idea that they’re sick, which can be especially troubling for people with diseases that are traumatic, stigmatised or painful. No one wants to dwell on their illness, but with each pill we ask patients to swallow, we also ask for tacit acceptance of this fact, over and over, day after day.
For some patients, taking medications creates an aversive sense of dependency, a sense of lost agency and control. Others have intrinsically negative views of medications – understandable given the myriad side effects, lawsuits and anecdotes.
And all these issues are more challenging with preventive medications than therapeutic ones. We tend to discount the future benefits of treatment, especially if we feel fine at the time: we’ll take painkillers for a sprained ankle today but neglect drugs to prevent a heart attack tomorrow.
Helping patients understand their illnesses and adhere to treatment has always been a professional responsibility of doctors. But increasingly it’s also a financial responsibility. Many new payment models emphasise keeping patients healthy – instead of reacting when they’re sick – thereby creating economic incentives for clinicians to promote medication adherence. Hospitals and clinics are also investing in technologies and initiatives to help patients take their medications: pharmacy-led phone calls to explain drugs and reduce complexity; apps that remind patients to take pills; insurers’ waiving co-payments or even paying patients to take medications; electronic prescribing that allows for real-time monitoring; and monthly reports for doctors to see which of their prescriptions were filled.
But physicians must also do a better job of explaining why, when and how patients should take medications. One study found that doctors spend less than a minute discussing new medications they prescribe. Another found that they fail to discuss the side effects of medications or how long they should be taken about two-thirds of the time. In a quarter of new prescriptions, physicians never state the name of the medication.
Fixing medication nonadherence is essential, but it may require as many solutions as there are causes. Progress hinges on having doctors and patients take the time to explore barriers, frustrations and opportunities – and recognising that diagnosis and prescription isn’t the end. It’s the beginning.
Khullar is a physician at NewYork-Presbyterian Hospital and a researcher at the Weill Cornell Department of Healthcare Policy and Research.