"I don't know what's going on with doctors!" Becky complained as she busily arranged the apples in her stall at my local farmer's market.
"Went to see mine, haven't had a good night's sleep in weeks, what with my legs moving around on me all night long... She gives me a pill for it... At the pharmacy, I find out it's for Parkinson's, for dementia! I may be many things but I sure as heck ain't demented, though George [her husband] might say differently... I'm not taking those pills, that's for sure."
"Did she prescribe...?" I mentioned a medication commonly used in this situation.
"Yes," Becky's eyes widened. "How did you know?"
Same Pill, Multiple Reasons for Use....
While it was true that Becky's medication was used to treat Parkinson's disease and some types of dementia, it was also effective in treating restless legs syndrome, which she appeared to be suffering from. I encouraged her to talk to her doctor and to not wait until her next appointment or not talk about her qualms at all, both of which options Becky was seriously entertaining.
In medical parlance, Becky was "noncompliant," a major impediment to health. Over time, the generic noncompliance has come to connote "disobedience" of a medical nature, particularly as it pertains to the adherence to medication regimens. Concerted attempts to adopt the term nonadherence, reflective of a partnership rather than a coercive or subordinate relationship, are slowly gaining traction. In Becky's case, the cause of her nonadherence was misunderstanding and a lack of trust in her physician, who was new to her.
Even in cases where physicians are trusted and beloved, nonadherence is a factor.
The "Good" Patient
"I am not taking my blood pressure medication," James, a family friend confided recently. "I don't have high blood pressure."
He showed me his medications, of which he takes only one of the three prescribed. He then shared his meticulous daily log, where his blood pressures were indeed stable.
"James," I asked. "Does your doctor know that you aren't taking some of your medication?"
"Oh, no, no." James answered. "He's a wonderful man, a great doctor. I don't want to tell him how to do his job."
James was no wallflower, he was the 80-year-old retired CEO of a global corporation. Even so, he feared offending his physician. James' wish to be a "good" patient jeopardizes his health, as similar medications are used to treat cardiac problem and hypertension, and his assumptions could expose him to heart disease. If he was, in fact, on multiple medications to primarily treat his hypertension, his physician still needed to know that he no longer needed them. Should James be admitted to a hospital, he may be placed on more medication than needed, based on his medical records, with possible deleterious consequences.
Sometimes too much information, and not too much or too little trust, is the issue.
"Mom!" It was my daughter on the telephone. "It says here I could have an allergy and die if I take this!"
Her pediatrician had prescribed a common antibiotic and the long laundry list of side effects on the mandated accompanying pharmacy pamphlet were frightening to her. Information from the internet adds to the confusion. Who do you believe? The blogger who needs a liver transplant as the result of the medication your doctor just prescribed for you? The Mayo Clinic (substitute University/Hospital name here) newsletter? What was told your wife's best friend by her eminent cardiologist? Aside from information, there are other more mundane barriers to adherence.
As one of my patients noted wryly, "I don't know why I bother with breakfast. I take enough pills every morning to fill my cereal bowl."
One of our nation's largest pharmacies, Medco, found that a quarter of seniors over age 65 take between 10-19 pills a day, and nearly a half take between four to nine pills daily. And that's prescription medication. Add to this number the usually unreported intake of numerous vitamins and herbal supplements. Both the total number of pills a patient takes and the number of times a day it is taken reduce medication adherence. This is a problem that will continue to worsen. In the United States alone, when comparing 1997 to 2004, the prescription purchases increased from 1.9 billion to 2.9 billion, increasing not just cost of prescriptions but the sheer number of medications consumed per patient.
While cost is often cited as a cause of non-adherence with medications, a recent study of nearly 6,000 patients recovering from a myocardial infarction found just 36 to 49 percent of these highly motivated patients adhered to medication regimens. The elimination of copayments improved adherence by a mere 4 to 6 percent. As the accompanying editorial headline in the New England Journal of Medicine observed, "Improving Adherence -- Money Isn't the Only Thing." This study also illustrates is that adherence isn't necessarily governed by the gravity of the illness -- few things are as alarming as the specter of a heart attack.
These data are in keeping with World Health Organization findings that just half of all patients with chronic illnesses in developed nations adhere to medication regimens. Aside from the real health and fiscal costs to the individual patient, society pays as well. Between 33 to 69 percent of medication related hospital admissions are due to non compliance, with costs exceeding $100 billion a year.
Given This, What Is a Patient to Do?
Here are my suggestions, culled from over two decades of patient care:
- One factor that invariably improves adherence, regardless of type and severity of the disease or the socioeconomic class or educational level of the patient, is time. Time spent explaining the need for the medication, how to gauge its effectiveness, probable and possible side effects. Time spent asking in a nonjudgmental way about quandaries posed by the medications and other recommendations, including diet and exercise.
- Another given is how frequently discussions, particularly regarding medications and their rationale for use, tend to be forgotten and need to be reiterated, often a few times a year for a chronic illness.
- Make an appointment with your doctor for the express purpose of educating yourself about the particulars of your treatment. Be candid about your concerns. This is not the time to worry about offending your doctor, worry about not being a "good patient"! Ask if there are specific call times where you can call in with questions between appointments if there are side effects.
- Make and keep current a simple table of your medications and supplements, the reasons for use, dosage and times of day taken, and share this with all your physicians. Keep a copy in your wallet.
- Use weekly pill boxes, I find them incredibly helpful in my practice.
- Consolidate your medications into as few times as possible, preferably just once a day, with the help of your physician.
- Incorporate pill taking into your routine, with breakfast and after the Late Show, for example. Revisit your medication regimen with your physician every year or two.
Remember, your health is an ongoing commitment on the part of both your doctor and you. Continually educate each other in the mutual pursuit of your optimal health.
Here's to your good health in 2012. Salud!
For more by Gayatri Devi, M.D., click here.
For more on personal health, click here.
 Choudhry NK, Avorn, J, Glynn RJ et al. "Full Coverage for Preventive Medications after Myocardial Infarction." New England Journal of Medicine 2011;365:2088-97.
 Osterberg L, Blaschke T. "Adherence to Medication." New England Journal of Medicine 2005;353:487-97
DiMatteo MR. "Variation in Patients' Adherence to Medical Recommendations: A Quantitative Review of 50 Years of Research." Medical Care 2004;42:3:200-209.
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