Adherence: Magnets, super glue and...patients?

Your moment has finally arrived! Alex Trebek stands before you and the Double Jeopardy Round has just begun. The category on the board is titled “Things that…” Alex reads the answer: “magnets, super glue, and patients.” You shout out “What are Things that adhere?!” and win the Double Jeopardy round by a landslide. Then you wake up… You remember that you are not on the set of Jeopardy and that, by and large, patients don't adhere. Bummer. But, at least you know magnets and super glue generally don't disappoint…

You've likely heard much of it before—on average, half of all people take their medication as prescribed, while 33% of patients never fill a prescription that is written for them.¹² To put it more simply, for every 100 prescriptions written, 50–70 go to a pharmacy, 48–66 come out of the pharmacy, 25–30 are taken properly, and 15–20 are refilled as prescribed.³⁴ Adherence rates in patients with mental illnesses often fall short of the rates described above that can be found in the general population.⁴ Bottom line: patients don't adhere. (Disclaimer: I include myself in the collective word “patients” because, between you and me, I can be a bit hypocritical when it comes to following my own advice as I teach my patients about medication adherence.)

What is it about medication adherence that has the healthcare world stumped? No matter how you define medication adherence, no matter what you call it, no matter how you go about measuring it, it is a challenge for healthcare professionals and patients alike. Yet, there is no shortage of information reminding us that medication non-adherence leads to sicker people, more hospitalizations, poorer quality of life and higher healthcare costs.⁵⁶⁷ So why the disconnect? Obviously there is no easy answer and no quick fix. The authors of several of the articles in this issue of the MHC point out some of the important notions to keep in mind regarding the conundrum that is medication adherence.

1. Medication adherence isn't solely the responsibility of the patient.⁸ It is hardly fair to set a patient loose with a piece of paper and a bottle full of expensive pills and expect them to be fully engaged medication-takers. Just like it takes a village to raise a child, it may take a village to properly educate, motivate, activate (and in some cases expectorate!) a patient. Tomko and Lizer, et al. describe how pharmacists can actively join the village in preparing the patient for medication adherence success.

2. Medication-taking behavior is influenced by a complex set of factors that are different for each individual. Creative solutions and thinking outside the box may be necessary when working with individual patients to meet their needs and engage them with their medication therapy. In her review in this month's MHC, Heesch describes how creative use of technology may impact patient medication adherence.

3. Talk is cheap where medication adherence is concerned. It's easy for patients and clinicians to talk about medication adherence without actually doing anything about it. However, creating a blame-free environment where patients can talk, really talk, about their medication concerns may go a long way in promoting their medication adherence. Ehret and Wang in their review article in this issue of the MHC, describe ways in which the approach to the patient and the discussion of their medication treatment may make all the difference while Jones's toolkit directs both patients and healthcare providers to resources that may come in handy with medication adherence discussions of all kinds.

As I consider my own occasional medication non-adherence and perhaps that of other pharmacists like me, I wonder how is it that despite knowing most of the facts, the stats, and the benefits of medication therapy, I still am not adherent 100% of the time? Not to mention the facts that I have a great relationship with my provider and that am blessed with adequate finances to afford prescriptions. These factors don't seem to be enough… Perhaps it's accountability that's missing. No one really expects me to take my meds 100% of the time, and the healthcare system accepts any excuse I might offer for my nonadherence. I am not advocating for hard-nosed militancy from healthcare providers, but a little challenge to my negligence would certainly be motivational! Or perhaps my nonadherence is related to lack of positive reinforcements. Of course, I recognize that medication-taking has its own intrinsic rewards (prevention of illness, reduction in symptoms, overall lower healthcare costs, etc.), but in our instant gratification-oriented society, those long-term benefits can seem very far off. If my current health plan, which allows me to earn points which can be redeemed for gift cards and merchandise when I engage in healthy behaviors (like regular exercise and healthy dietary choices), incentivized my medication adherence in the same way, it just might change the way I approach my medication-taking. But, I recognize that even if these ideas worked with me, it is likely that accountability and/or external rewards would have no impact whatsoever on others. So, there may not be a one-size-fits-all solution to a medication adherence problem in our country. But I would argue that a host of individual solutions, including the exploration of what each individual needs, desires, believes and dislikes when it comes to medication-taking may be called for in order to make each one of us more “glue-like” with our medications.