Medication Adherence

Fifty years ago, few talked about medication adherence or compliance, the degree to which patients follow their physician’s instructions usually in taking prescribed medications. It was not an issue because health care providers primarily treated acute disease or illness. If you had an infection, for example, you likely received a drug to clear it up so you could go back to your normal activities. Even if you didn’t take medicines prescribed for you, the infection often disappeared by itself. Most patients, however, took the brief course of prescribed drugs because they wanted relief from the symptoms they were experiencing. All of this changed in the past 50 years for two basic reasons:

First, there has been a shift in health care towards treating chronic illness. The traditional treatment model was based on treating acute physical diseases or disorders. Here, the patient is a passive recipient of care with a condition that is likely to be short-lived. In recent decades, however, more attention has been directed towards using a treatment model that also includes chronic conditions. Five years ago, chronic physical and mental conditions accounted for 47% of the global burden of disease. In terms of sheer number, the World Health Organization (WHO) estimated that chronic diseases were responsible for more than 24 million deaths a year, or about half of the global total. The leading causes of death cited by the WHO were (a) circulatory diseases, including heart disease and stroke; (b) cancer; and (c) COPD. The burden of chronic illness leading to death is projected to increase to 60% by the year 2020 with heart disease, stroke, depression, and cancer leading the way. In addition, progress has been made in treating conditions, such as some cancers and HIV/AIDS, so that they no longer are automatic death sentences; they too may become chronic health conditions with proper treatment. As life length in developing countries continues to increase-- life expectancy at birth in the world reached 65 years in 1996--an aging population will begin to experience an even higher rate of chronic diseases and conditions.

Second, a different approach to treating chronic conditions has occurred, sparked both by the magnitude of the problem and by the number of drugs introduced to control and maintain these conditions. If you have hypertension, for example, you might be prescribed a medication for your condition. The drug is not designed to relieve symptoms of the illness--you likely do not experience symptoms--but to keep hypertension under control. Other maintenance or controller medications were developed and launched for conditions ranging from asthma to migraine and from diabetes to high cholesterol. If taken as directed, the medicines will help you establish control or, as is increasingly the case, prevent the onset of a chronic condition such as diabetes. If the treatment regimen prescribed for you is effective, you will remain without symptoms. If a drug is not effective, the conclusion by health care providers is often that it didn’t work because you didn’t take it as directed. This behavior is referred as the lack of medication compliance or, to use a term more friendly to health care providers, medication adherence. The distinction between the terms is purely cosmetic as there is no difference between the terms compliance and adherence (there is also no evidence to suggest that using adherence over compliance improves patient behaviors in taking prescribed drugs).

The reason chronically ill patients are blamed for not adhering to medication instructions is because of data reported on their rate of compliance to treatment regimens. Study after study has concluded that patients are adherent about 50 percent of the time to treatment regimens. What exactly do these data mean? Do they mean that all patients are adherent only half of the time? No. If you look at patients’ behavior, it is easy to show that some people never or rarely comply to medical instructions while others adhere all or almost of the time with instructions. Does the 50% figure mean that patients only take half of their directed medications? Not really: patients usually take the entire dose of their drug when they take it. It is an all or nothing proposition, not a 50-50 activity (although some patients may reduce their dosage of a drug to make their prescription last longer). What exactly does the 50% adherence rate indicate? Here the explanations become murky, although the sheer number of people with chronic illness is beginning to shed some reasons for the figure.

If the figure of 50 percent compliance had initially been taken as a call to develop better ways of teaching patients to self-manage their illness, it would have been an advance forward. Unfortunately, this demand for this action is only now being heard. There is no doubt that self-management increases medication compliance, at least for as long as a patient is involved in a self-management program. The 50% compliance rate has traditionally been viewed as the fault of patients not following the instructions of their physicians or health care personnel. This perception is found throughout the literature, including the conclusions of a recent report from the WHO on the topic of medication adherence. This has resulted in a “blame game” by health care providers that is often hard to change. After all, taking medications is purely a decision of individual patients as they are solely responsible taking drugs properly, changing lifestyle patterns, and attaining the management standards recommended by their health care providers. However, the blame game is very unproductive. There are enough problems to solve by both patients and health care providers in order to insure medication compliance occurs without shifting the blame as due to patients. Blaming others is not only unfair and erroneous, but it has helped contribute to the many barriers that plague the topic of adherence. Physicians and patients must continually work together if higher levels of medication adherence are achieved. This is the major riddle facing compliance in chronically ill patients. Factors involved in the riddle will be further described in further entries.