The other drug problem

Neglecting to take medicines as instructed is one of the most serious and under-reported problems in medicine, writes EOIN BURKE KENNEDY

IT’S KNOWN in healthcare circles as “the other drug problem” and is estimated to cost billions of euro each year in increased hospital admissions and unnecessary GP consultations.

The World Health Organisation (WHO) estimates that up to 50 per cent of patients with chronic disease do not take their medication as prescribed.

Non-adherence – the medical term for neglecting to take medicines as instructed – is one of the most serious and under- reported problems in medicine.

Because the issue spans across a range of therapeutic areas, the scale and cost of the problem is not easily quantifiable.

A recent US study estimated non-adherence costs the economy €300 billion annually and accounts for up to a quarter of all hospital and nursing home admissions.

In a submission last month to the consultation process of the Irish Government’s National Positive Ageing Strategy, the Irish Pharmaceutical Healthcare Association (IPHA) said up to 50 per cent of cardiovasculardisease admissions were due to poor adherence to medication.

A recent study on asthma patients in Northern Ireland founddifficult-to-treat asthma was more often than not linked to patients who did not take their medication as instructed rather than ineffective medication.

It’s long been established that patients’ failure to take immunosuppressive drugs is one of the primary causes of organ transplant failure.

Similarly, psychiatrists frequently cite poor medication compliance as a cause of relapse in the treatment of depression and other psychiatric disorders.

Failing to follow prescriptions can range from simply forgetting to take the pills to skipping days, altering doses or failing to take them altogether.

The reasons for non-adherence are various and complex, and relate to disease severity, side effects, duration of treatment and frequency of dose.

It has been shown that people are less likely to continue their medication regimens over long periods when the daily doses increase from one pill to four pills.

Irish College of General Practitioners (ICGP) spokesman Dr Mel Bates says there are few or any adherence problems when it comes to the big drugs like anaesthetics or chemotherapy where the effects are immediate and patients are well motivated.

The challenge for many doctors is getting people to take medicine “when they feel fine whether they take their pills or not”, says Bates.

Blood pressure patients can often become complacent about taking the tablets because they don’t get “instant feedback” from the medicine, he says.

“But it is the lowering of blood pressure over several years or even decades that lessens the risk of stroke.”

Bates says adherence rates can be affected by the number of tablets people have to take, the number of times a day they have to take them, and by the likely side effects they may suffer.

“The ideal tablet would be single dose, once a day, with no side effects.”

A well-informed patient who understands why he or she is taking the medication is more likely to adhere to a regimen, Bates says.

There is no consensus in the scientific literature to suggest that adherence rates deteriorate with age. But as older people suffer more illnesses and consume more medicines than their younger counterparts, adherence is a significant issue in geriatric medicine.

Some 47 per cent of all prescribed medicines in Ireland are consumed by those aged over 65, according to the Health Service Executive, and nearly two-thirds of people over 60 suffer from two or more chronic conditions.

Research published last year by the Royal Pharmaceutical Society of Great Britain (RPSGB) suggested older people were taking a “cocktail of medicines” without fully understanding what it was for or the side effects it may be causing.

The RPSGB’s survey showed nearly half of over-65s were taking more than five medicines at any one time, and more than 20 per cent admitted to not always taking the medicine as prescribed.

In an attempt to address poor adherence, US scientists last year developed a necklace that records the date and time at which a patient swallows their medicine.

The device contains an array of magnetic sensors which detect a tiny magnet in the medication as it passes down the oesophagus. The information is then relayed to the doctor or care-giver via the internet.

The technology follows on from a drug-filled prosthetic tooth that releases a dose of medication at regular intervals and a pill bottle that sends a wireless message to the pharmacist every time it’s opened.

Many experts believe such devices reinforce the paternal view of the doctor-patient relationship, which may be a cause of poor adherence in the first place.

A seminal US longitudinal study conducted in the 1990s found the physician’s role in dealing with patients’ concerns strongly influenced whether or not patients stayed on their medication.

The study of 186 physicians and their diabetes, hypertension and heart disease patients, found the tendency of doctors to answer patients’ questions was linked to adherence.

Consequently many recent studies on the issue of adherence have advocated developing more intensive doctor/patient relationships whereby patients are more informed about the medication and what the therapy seeks to achieve.

An IPHA spokesman says despite the introduction of new medicines which have fewer adverse effects and are more convenient to use, many people still do not take them as prescribed, even when not doing so can have life-threatening consequences.

He says the cost of medicines has long been established as an influence on adherence.

“As recession bites, it’s conceivable that some patients may attempt to stretch their prescriptions out over longer periods or wait longer to get a prescription refilled to save money.”

He says there are many private patients just over the medical card limit, who may be making decisions about medications on the basis of cost.

A survey, published last week, in the 2009 Pfizer health index found strong evidence that Irish people were cutting back on both prescribed and over-the-counter medicines because of the recession.

The survey found 14 per cent of adults admitted to reducing their spending on prescription medicines, while some 24 per cent said they were more reluctant to visit a healthcare professional in the current downturn.

While the cost of medicine undoubtedly plays a factor in the higher adherence rates witnessed in countries like Sweden and Japan, a straight reading of the correlation may blur certain cultural differences, which may also affect adherence.

In Japan, for instance, doctors sell as well as prescribe medicines to patients, giving them an economic incentive to ensure patients stay on their regimens.

As the Pfizer survey indicates, the problem of non- adherence is not confined to prescription medicine.

A 2005 survey, conducted on behalf of the IPHA, found 46 per cent of Irish people did not read the information leaflet enclosed with non-prescription medicines such as cold, flu and hay fever medications.

It also found that when it came to seeking advice, only 50 per cent of people asked their pharmacist for advice on non-prescription medicines, and more than 25 per cent did not read the label/box/bottle before taking non-prescription medicines.

Some 20 per cent people were taking prescription medicines at the same time as non-prescription medicines, and some 16 per cent admitted consuming alcohol while taking non-prescription medicine.

The Irish Medicines Board (IMB) advises patients to always take their medicine as instructed by their pharmacist or doctor and to finish the course of treatment unless advised otherwise by their healthcare professional.

In addition, the IMB urges people to read the patient information leaflet which accompanies their medicine as it contains all the information relevant to the use of that medicine.