September 2, 2016 / All Stories

The surprising reasons people don’t do what the doctor ordered

Half of all people with chronic diseases don’t take their medications as directed. Finding out why is only half the battle.

When Beth Dere developed severe pre-eclampsia while pregnant with her first child, her doctor prescribed medication to control her blood pressure. Nine months later, the Overland Park, Kansas, U.S.A., teacher was thrilled to see her numbers return to normal. So thrilled, in fact that she decided to stop taking her medicine.  

By the time she felt sick enough to go to the doctor, her blood pressure was dangerously high. “I just assumed I was all better,” she says. “Of course I now know it was because of the meds doing what they were supposed to do, but at the time I thought I was healthy enough to stop taking my pills.”

Dere isn’t alone. Approximately 50 percent of patients with chronic conditions do not take their prescribed medication as directed, either stopping the medication prematurely, taking it in a manner other than what’s been prescribed, or never filling the prescription in the first place. This is defined as medication non-adherence, and it’s a problem costing the United States 125,000 lives and $289 billion annually. 

The entire health care industry, from physicians to insurers to pharmaceutical companies, agrees that this is a massive problem. Where there’s less agreement is on the whys of medication non-adherence: why don’t people take medicine like the doctor ordered?

Can't, won't or don't?

The varied, layered reasons behind non-adherence makes it a complicated issue to solve. Unpleasant side effects, lack of transportation, depression, forgetfulness, being on too many different medications, and cultural and language barriers have all been shown to make patients less likely to take medication as directed. 

Complicating the issue even more, a large number of patients who don’t take medications as directed are choosing  not to, just like Dere did.

Sometimes these decisions are made due to a lack of “health literacy” (the ability to access, understand and process adequate health information). But, says Dr. Marie Brown, associate professor of medicine, department of internal medicine, at Rush University Medical Center in Chicago, Illinois, “we can’t put the burden on the patient to understand what we want them to understand … The pharmaceutical industry, hospitals, health care providers … It’s on us to provide the information in an understandable fashion and not blame the patient.” 

Dr. Brown, who has authored several articles and lectured on the topic of non-adherence, says not only should prescribing physicians ask patients the right questions, but they should pay attention to how they do the asking. 

“Something as simple as asking a patient, ‘do you have any questions?’ – on first blush, that looks like a really thoughtful caring assessment that you’ve communicated what you need to communicate,” she explains. “But because of the way the question is framed … to the patient, it might sound like if you do have questions, you aren’t smart enough.” 

Instead, she suggests that care providers ask “what questions do you have,” which implies that the patient should have some questions and opens up the conversation.

Offering answers before the questions

Understanding why and how you should take your medicine doesn’t mean it’s easy to do so. For those with chronic conditions, taking a pill – or 20 – every day for the rest of your life can take a toll, on an emotional, physical, social and financial sense.

The more medications a patient is on, the more likely they are not to take all of them as directed. The same goes for complex medication regimens. Newer, easier drug delivery systems are an industry goal, but when you’re trying to treat a complex, chronic disease there isn’t always an easier option.

To help address both of these issues, patient programs have been created to provide both education and support for those with chronic diseases.

(These programs) are designed to assist patients … helping them learn what to expect and how to use the medications properly, and understand not just the physical and procedural hurdles but also the psychological hurdles that come along with beginning a new long term therapy,” says David L. Van Brunt, Ph.D., senior director, health economics and outcomes research, immunology. His team studies the impact of such patient programs for AbbVie.

The challenge facing patient adherence

Tech companies have been jumping on the patient adherence bandwagon, offering high-tech solutions like medication reminder apps for this widespread problem. But as Brown points out, “when the vast majority (of people) aren’t taking their medicine because they choose not to, then an app isn’t going to fix the problem.” 

These same patients may be hesitant to admit they aren’t using medications as directed, because they may want to please the doctor or avoid being admonished, Brown says. She urges physicians to show respect and appreciation when the truth does come out. “Thank them for being honest; tell them lots of patients don’t take their medicine and say, ‘let’s talk about why.’ If you talk to 10 patients, you will hear 10 different reasons.”

These 10 – or more – reasons can’t all be addressed overnight, but there’s no question they must be. The consequences of not taking your medication are dire; for example, people with hypertension are 5.4 times more likely to face hospitalized or premature death. And with around 75 percent of adults being non-adherent in some manner, that adds up to a lot of people getting unnecessarily sick. Taking ownership of the medication adherence epidemic is an essential first step.

“The problem of medication non-adherence isn’t going to go away,” says Joette Gdovin Bergeson, Ph.D., MPA, vice president, health economics and outcomes research, oncology, neuroscience. “It’s something we as a company (and society) have to commit to, making sure patients have everything they need to take their medicines and help prevent their illnesses from getting more severe.”

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