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Proper adherence to medication regimens is an important yet frequently overlooked aspect of treatment for many diseases. A recent article by P. Michael Ho and colleagues found that more than one in five patients were not taking their medications for diabetes properly. Nonadherence was associated with higher glycated hemoglobin (A1C), blood pressure, and LDL cholesterol levels. In addition, every 25% increase in medication adherence was associated with reductions in these three measures.1
"Adherence is when the patient is taking the medication in a way that is both beneficial and agreed to by both the patient and the prescriber," says Jill Crandall, MD, associate professor of clinical medicine at Albert Einstein College of Medicine in Bronx, New York. "I define it this way because often the process is more one-sided, with the physician making a decision and then considering it poor adherence when the patient doesn't do exactly what the physician said. I think we need to take this discussion out of the context of unilateral decision-making and make it more of an agreement between the two."
Major changes in available therapies, especially medications for chronic diseases with proven efficacy, have brought more focus on the need to properly take the new treatments.
"Prior to the last 40 years, there were not a lot of regimens that actually worked, so compliance was less of an issue," said Patrick O'Connor, MD, family physician and senior clinical investigator at HealthPartners Research Foundation in Minneapolis. "A good example of this change is cholesterol. If a person with high cholesterol takes medication that effectively lowers their cholesterol for a long period of time, they can cut their risk of heart attack by 35% or more in some cases. If you don't take the medications, you don't get the benefits."
DANGERS OF NONADHERENCE
Assessing nonadherence with medication prescriptions should be an important part of every visit with each physician a patient is seeing.
"The methods to do this are not well taught in medical school," says Lars Osterberg, MD, chief of general medicine at Veterans Affairs Palo Alto Health Care Systems and clinical assistant professor of medicine at Stanford University in Palo Alto, Calif. "Patients usually want to please their doctors and will always be in total compliance when they are asked if they are taking their medications. It is important that these questions be phrased in a manner that lets them be more frank with you."
Clinicians should tell patients that they know medications are hard to take and ask them what tricks they use to remember when and how to take prescribed drugs. Having the patients bring their medication bottles to the visit allows the physician or nurse to see the last time the prescription was filled and how many pills remain. Patients should be asked about problems they are having and should be allowed an opportunity to share concerns. Above all, the physician or nurse should be nonjudgmental.
Nonadherence can cause unforeseen problems if not found. In addition to the obvious concerns about less than therapeutic doses, dose escalation presents a danger.
"It may seem that the dose isn't adequate when in reality the medication isn't being taken," says Crandall. "You can keep increasing the dosage based on nonresponsiveness or other criteria. If the person eventually decides to take the dose that was prescribed based on this faulty information, the results can be catastrophic."
One of the larger barriers to adherence may be related to how the physician communicates when prescribing new medications. Derjung Tarn, MD, assistant clinical professor in the Department of Family Medicine at the David Geffen School of Medicine at University of California Los Angeles and others undertook an observational survey where they audiotaped 185 outpatient encounters involving 18 family physicians, 18 internists, and 11 cardiologists. They found that 26% of the time the doctors did not even mention the name of the newly prescribed medication and 13% of the patients were not told the purpose of the medicine. Just over half the encounters included explicit instruction about the number of tablets to take or the frequency and timing of the doses. Adverse effects and how long patients were to take the medication were discussed during only 35% and 34% of the interactions, respectively.2
BECOME A MEDICATION COACH
"Your first step to improving adherence is to emphasize the value of the prescription to the patient," says Osterberg. "Just saying it lowers cholesterol tells the patient next to nothing. Instead they should know that it will reduce their chance for a heart attack or stroke. Until you have a conversation that includes an explanation and then understand where the patient is coming from, you aren't going to get the therapeutic alliance that will get them to buy into taking the medication."
Primary care physicians can help lessen this problem. The experts suggest coaching patients before they see the specialist. Some physicians even assist the patient by writing out specific questions to be asked about the treatment protocol, including medications.
"Inferior communication can lead to many serious problems," says O'Connor. "I had a patient where one physician had prescribed metformin (Glucophage XR, Bristol-Myers Squibb) and another had given her Glucophage. She was taking the medication out of both bottles because they were labeled with the different names and the pills looked a little different."
He had another patient taking a cholesterol medication. When O'Connor asked about his medication, the patient related that a few months earlier the medication ran out and the bottle instructions stated "do not refill," so he didn't. He had interpreted this as meaning he no longer needed the medication.
These are indications of what O'Connor calls "penicillin thinking." Patients may think that after a certain amount of time the medicine has done its work and is no longer needed. Communication with the patient about such issues should be an important part of the original prescription teaching and should be ongoing at every visit.
Ease of taking the required medications is another important aspect of adherence. "The less work done by the patient, the easier it is for them to accept and keep up with medication requirements," notes Crandall. "This pertains not only to limiting the number of pills and times they need to take medication, but also can be impacted by the delivery system. For example, many people find insulin pens easier to manage than vials and syringes."
The patient's lifestyle and financial situation should enter into the compliance equation. This can be an especially difficult assessment because of the social taboo against discussing money issues.
Therapeutic relationships are important in adherence. When patients don't like the doctor, they often are less motivated to please and trust him or her.
"A component of nonadherence is physician communication or bad rapport," says Osterberg. "Although both physicians and patients are responsible, the doctor should not feel that is entirely his or her fault. But I don't want to take the physician completely off the hook because we tend to do a poor job of communication."
Another component to improved adherence is patient understanding and
acceptance. Patient understanding is influenced by the physician's
communication skills and ability to coach patients to achieve agreed upon
goals. 
Talking About Drugs
When discussing medications with patients, be sure to highlight each of the following areas:
Source: FDA and You: News for Health Educators and Students Newsletter. Available online at www.fda.gov/cdrh/fdaandyou/issue/O.html#4.
Footnotes
Consumer materials on the safe use of prescription medications are available from the Food and Drug Administration's Web site at www.fda.gov/usemedicinesafely/ensuring_safe_use_text.htm.
A list of preventive measures for the HealthPartners diabetes disease management program can be viewed at www.healthpartners.com/files/22799.pdf.
Medication safety tools and resources are available from the Institute for Safe Medication Practices at www.ismp.org.
References
2. Tarn DM, Heritage J, Paterniti DA, et al.: Physician communication
when prescribing new medications. Arch Intern Med 166: 1855–1862, 2006.
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