Non-Adherence versus Non-compliance
Non-compliance means refusal to comply or follow a dosage regimen. This term depicts a dosage regimen as a “command”; patients should obey what they are told to do and there is no collaboration with the patient. As a patient, I always felt intimidated as the nurses yelled across my bed “patient refused medication”. I felt like a child who was not obeying their parent’s advice. However, I was refusing it because there was no need for it (in my opinion).
Non-Adherence is the new way of saying “non-compliance”. This new terminology represents both a patient’s beliefs or life choices and scientific data. Under the umbrella of compliance, prescribers just expect patients to follow whatever they prescribe. However with the concept of adherence, healthcare professionals are encouraged to consider the patient’s lifestyle, beliefs and other factors that may affect how they take their medications. For example, a doctor who would have prescribed metronidazole will switch therapies to clindamycin because the patient will not stop drinking alcohol. The burden is no longer on the patient to choose between medications and their long-standing social history. This does not mean healthcare professionals are endorsing any particular lifestyle. This only means that, in the prioritization of the patient’s current health issues, we are more concerned about treating the more urgent disease. Approximately 30-50% of patients with chronic diseases are non-adherent to their medications which translates to about 100 billion dollars in preventable cost.
Also read How to Improve Medication Adherence.
Lack of realistic therapeutic goals
Some patients view certain treatment goals as unreachable and unrealistic. To these patients, taking medications is a total waste of time because they do not think they can ever get to the goals that are set for them.
Rather than setting the bar so high, lets break the goals down for the patient. Credits should go to JNC7 for breaking hypertension goals down for patients so they see that every little effort helps. For instance limiting alcohol consumption to <2 drinks per day will decrease systolic blood pressure (SBP) by 2-4mmHg (for men). This motivates patients to take baby steps.
Cost of medications
Cost has a huge impact on medication non-adherence. If patients cannot afford the medication they will not purchase or take it.
Healthcare professionals should take into consideration the economic status of a patient before they recommend any medication. Not all drugs have generics on the market but there may be a therapeutic equivalent available. For instance, a prescriber may write for omeprazole if the patient cannot afford Nexium. Prescribers can try other second line or third line choices if they are cheaper. Pharmaceutical companies should have more prescription assistance programs or samples to be given free to patients that qualify and the federal government or the state can provide assistance to patients who cannot afford their out of pocket cost.
Also read Help for Saving Money on Prescription Drugs.
The side effects of some drugs are terrifying and some patients will rather not take those medications. Infomercials provide a long list of side effects that are recited without proper context.
Pharmacist should counsel patients about their medications. They should assure the patients that some side effects are minor and not all patients actually experience them. They should clarify the risk versus benefits of taking a medication.
Medication does not provide immediate and visible benefits
Some patients do not take their medications because they don’t see any physical changes in their bodies after they take the medication.
Patients should be educated that some diseases are silent killers. And even though they may not necessarily see any changes in their body, the drug is doing a lot internally to prevent premature death. Healthcare providers should counsel patients about what to expect from drug therapy.
Don’t know how to take or use it
Some patients do not take their medications because they simply do not know how to take or use it. There have been instances where patients have either swallowed a suppository or used a suppository without unwrapping the medication.
Omnibus Reconciliation Act of 1990, requires pharmacist to counsel Medicaid patients. Some states such as California has extended this law to all patients. In California, pharmacists must offer counseling to all patients on new prescriptions.
Past experience with medications
Some patients do not take their medications because of past negative experiences with the same or similar drug. In their opinion, they are allergic to those medications.
A patient’s definition of an allergic reaction is different from a true allergic reaction. Healthcare professionals should explain to patients what a true allergic reaction is. This will help patients to better understand their response. They should also educate patients that similar drugs may have slightly different effects.
Complexity of medication regimens
Some medication regimens are too complex for some patients to follow. For example, warfarin dosage changes according to the patients International Normalization Ratio (INR). A patient may be required to take different doses on different days to reach a therapeutic INR goal.
Prescribers should make sure that the drug regimen is easy enough for patients to follow. All patients should receive the simplest dosage regimen.
Cognitive impairment prevents patients from understanding and remembering how to take their medications.
Cognitively impaired patients need care givers and advocates to assist them with their medications. Also read Confusion, Age and Medication Adherence.
People have busy schedules, and taking a medicine at a particular time everyday may not be as easy as it seems. Patients simply forget to take their medications.
Patients should schedule their medications around other daily activities such as meals or brushing their teeth. With today’s technology, smart phones can be programmed to send reminders. Patients who have smart phones should be encouraged to set up medication reminders and use pharmacy apps.
Directly observed Therapy (DOT) is recommended by World health Organization (WHO) for Tuberculosis. Under DOT, healthcare professionals make sure that patients take their medications. Patients are usually required to go into the facilities to take their medications. Even though this approach seems very tedious for both the patient and the healthcare worker, studies have shown that it is less expensive than traditional therapy for both in-patient and out-patient health care. The obvious reason being the prevention of noncompliance-induced extensions of therapy duration relapses and acquired resistance. The savings and benefit of adherence far exceed the additional manpower and transportation costs incurred with DOT. Not all patients are candidates for DOT, but healthcare workers can take the medications to the patient’s home.
Donovan JL and Blake DR ,1992 . Patient non-compliance : deviance or reasoned decision-making ? Social Science Med Mar;34(5):507-13.
Frost and Sullivan. Patient Non adherence. Tools for Combating Persistence and Compliance Issues.
Irina Cleemput, Katrien Kesteloot, Sabina DeGeest, 2002. A review of the literature on the economics of noncompliance. Room for methodological improvement, Health Policy, Volume 59, Issue 1, January 2002, Pages 65-94, ISSN 0168-8510
Jonathan S Olshaker, Robert A Barish, Jerome F.X Naradzay, David A Jerrard, Ellen Safir, Larry Campbell. Prescription noncompliance: contribution to emergency department visits and cost. The Journal of Emergency Medicine, Volume 17, Issue 5, September–October 1999, Pages 909-912, ISSN 0736-4679.
Marcum ZA, Sevick M, Handler SM. Medication Nonadherence: A Diagnosable and Treatable Medical Condition. JAMA.2013;309(20):2105-2106. doi:10.1001/jama.2013.4638.
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