Q) I sometimes forget to take my cholesterol pill. That’s not really a problem is it?
A) The word we use in medicine to describe situations that occur when a patient fails to take a drug exactly as prescribed is called non-compliance or non-adherence. Regardless of the term used, the problem is real and is reaching epic proportions.
According to statistics from our neighbours to the south, the number of people that do not take their medications regularly and the financial and heath costs associated with these decisions affects more people and costs more dollars than any single disease does in the country.
According to a review published in the Annals of Internal medicine, studies consistently show that 20 to 30 % of prescriptions are never filled and 50% of prescriptions targeted at controlling chronic conditions such as diabetes are not taken as regularly as they are supposed to be. In fact, many seem to take their drugs only half as frequently as they should be. The Annals estimates this costs the US healthcare system between 100 to 289 billion dollars each year while being responsible for 125,000 deaths a year and being listed as the main factor behind at least 10% of all hospitalizations.
While the problem is well known and completely preventable, it has proven to be a tough problem for healthcare professionals to solve. The challenge is that the reasons behind non-adherence are many and not frequently resolved with a simplistic discussion of the facts.
A classic example is the lack of use of prevention type inhalers (such as the corticosteroids ones like Flovent) in kids with asthma. Many parents are uncomfortable with keeping their child on any drug long-term and therefore stop these inhalers shortly after a flare-up. Frequently the child’s breathing does not worsen upon stopping the steroid inhaler causing the parent’s to assume their decision was wise. However, in many kids there is an underlying inflammation going on within their airways that without regular treatment can result in permanent damage to their respiratory system as well as increased risk of minor colds progressing to severe lung infections. These often require antibiotics and perhaps steroids taken by mouth to treat which have many more side effects than their inhaler counterparts do.
Another reason for non-adherence is that some do not take medications because they are a reminder that they are sick and who wants to be reminded of that daily? Others prefer a natural alternative (such as salmon oil for cholesterol) or lifestyle changes (such as losing weight) which are, in general, great options to pursue additionally but are usually not effective enough on their own to adequately replace the vast majority of prescription drugs regardless of the disease state being treated.
Others base their decision on a trial discontinuation such as so many asthma parents do. They stop their pills and decide after a week to stay off them if they don’t feel any different. This can have serious long-term consequences for drugs that treat “silent” conditions such as high blood pressure, cholesterol or certain heart conditions.
There is also no doubt that the cost of prescription drugs plays a role in non-compliance. For the working poor, or even those in the so-called middle class who get prescribed a $4000 a month biologic for their autoimmune disorder, paying for their drugs can make other necessities difficult to afford and even the littlest luxuries unattainable. A study in Pittsburgh showed that when people who had survived a heart attack were given free medications and compared to another group that paid for their drugs, the free group’s adherence improved by 6% and strokes and additional heart attacks were decreased by 11%. This is one of the main arguments to be made in support of a national Pharmacare system as we discussed in some detail last spring in this column.
Another common reason people stop taking their drugs is the belief it is causing them side effects. Many times this is valid. However, there are many times we blame drugs for changes in our general health when the drug is completely faultless. They make a great scapegoat and blaming then can ease our anxieties that we may be getting sicker/ older. If you have just started a new drug (or manufacturer as many times the same drug can be made by a number of drug companies which may use different additives such as dyes or glues) or changed the dose, and you feel bad, it is quite likely that the drug is to blame. However, if you have been on a drug for more than a few weeks, the likelihood that your prescription drug is suddenly causing you to experience unpleasant effects is far less certain.
Lastly, part of the blame for non-adherence lies with us, your health professionals. As all members, regardless of discipline, struggle with ever increasing demands we sometimes do not take the necessary time to properly educate our patients as to why this drug is important to their health and how they will typically feel on it. Telling some people that, for instance, a drug may lower their blood sugars has little impact when compared to spending a few minutes and explaining that doing so will greatly reduce their chances of suffering a heart attack, having burning pains in their feet, losing their vision and struggling with erectile dysfunction for the rest of their lives.
Regardless of the reasons behind any individual’s non-compliance, it is upon all of us to help overcome this whether it be the patient themselves, family/ friends or their healthcare professionals. Failure to do so will continue to break our government budgets and, more importantly, jeopardize the quality of life for so many of us. For more information about this or any other health related questions, contact your pharmacist.