Prescription pitfalls: why do patients not always take their medicine?
MEDICAL MATTERS:On a recent house call I was reminded how loosely some people comply with medication. My patient went rooting in a press to check the name of a new medication she had been put on by a hospital doctor. I noticed large quantities of creams and several boxes of osteoporosis medication stacked on the shelf. These medications were part of her routine monthly prescription. After some gentle probing it emerged that she hadn’t used the osteoporosis drug for over two years. The cream was still used but only intermittently; a tube a month was clearly in excess of her current needs.
Later at the computer as I was modifying her monthly prescription to reflect the reality of her current medicines adherence, I reflected on how lack of compliance contributed to unnecessary hospital admission. Not to mention the waste of resources in a cash-strapped public health service.
A study just published in the journal JAMA Internal Medicine looked at some 9,377 patients taking medications to lower their blood sugar, blood pressure or cholesterol. These patients were asked through questionnaires to rate how well their doctors communicated with them.
Patient medication adherence was determined by measuring delays in refilling prescriptions. The patients who gave their doctors poor marks in communicating were less likely to adhere to their medications.
Lead author Dr Neda Ratanawongsa, assistant professor at the University of California’s department of medicine, said “30 per cent of people were not necessarily taking their medications the way their doctors thought they were. Rates for non-adherence were 4-6 per cent lower for patients who felt their doctors listened to them, involved them in decisions and gained their trust”.
Non-compliance with treatment usually involves a number of factors. Another common cause is forgetfulness. The psychological mechanism of denial could be at work: having a disorder is upsetting and having to take drugs is a constant reminder of your illness. Or the patient may not have “bought in” to the prescription during the consultation with the doctor. He may be concerned about particular side effects, and is therefore reluctant to take the medication.
Other reasons for not complying with drug treatment include anxiety about the cost, misinterpreting the instructions, stopping the drug too early (this frequently happens with short-term prescriptions of antibiotics for infections) and even having difficulty opening the tablet bottles.
Despite all this, most non-compliers get better or at least their condition does not seem to worsen. What does this say about the treatment?
It could be useless: the scientist who “proved” that one tablet three times a day for five days was the required dose was wrong; the placebo effect – in which patients improve when given an inert dummy pill for its psychological benefits – has come into play; or they may have benefited from vis medicatrix naturae, the healing power of nature and the spontaneous return to health that would have happened anyway.
And at a time when the prescription of generic versions of drugs is being heavily pushed comes research suggesting the shape and colour differences between branded and generic drugs could be contributing to non-adherence. The Harvard study found that changing the colour of tablets contributed to people with epilepsy stopping their medication.
The doctor’s role
Medicine has traditionally focused on patients’ “bad” behaviour as the reason for non-compliance with treatment. What about the doctor’s role in non-adherence? Could the prescription have been written incorrectly? Was the doctor having a bad day, leading to a rushed consultation and a failure to adequately explain the treatment, its benefits and its side effects?
People are more likely to comply if they are told what to expect during treatment and if they believe the doctor really cares whether they follow the treatment plan.
Of course, 100 per cent compliance is an impossible goal, if only because we are human. The coalface of medicine will always have a ragged edge.