BETHESDA, MD 11 October 2012—When patients don't take prescribed medications to control their chronic illness, part of the reason is unwillingness to accept what it means to be a person with a chronic condition, says Bruce Lambert.
The University of Illinois at Chicago clinical professor of pharmacy practice, speaking September 10 at a conference sponsored by the Agency for Healthcare Research and Quality, explained medication adherence problems from an anthropologic perspective.
Lambert said people form firm ideas about their identity and resist incorporating into their life story anything that disrupts their self-image. A chronic illness diagnosis, he said, interrupts the trajectory of a patient's life.
In this model, taking a medication for that illness requires a patient to acknowledge and accept a change in identity. Refusing to take the medication allows patients to retain their self-image.
"Our paradigm for understanding what motivates [patients] is just completely wrong," Lambert said. "What really motivates people is this desire . . . to hang onto some preferred sense of self. If medicines help with that, people will take them. And if they don't, they won't."
Lambert said medical professionals often fail to understand that patients don't see medications as the answer to regaining their self-identity.
Sometimes, he said, medication therapy itself can cause changes that threaten the self-image, such as antihypertensive drugs that cause impotence.
Lambert said getting away from a purely biomedical model of medication adherence and using psychosocial tools like motivational interviewing is probably a step in the right direction for improving adherence.
Medication adherence. A report released in 2008 by Medco Health Solutions Inc. found that 51% of insured Americans were taking at least one medication for a chronic condition.
But as many as half of those people don't take the medications as prescribed, according to some estimates.
NEHI, formerly the New England Healthcare Institute, in 2009 cited poor adherence as one of the "drug-related problems" that account for up to 13% of total health care expenditures, or $290 billion annually in unnecessary costs.
Cynthia Rand, professor of medicine at Johns Hopkins University in Baltimore, said nonadherence is "a lot more complicated" than simply forgetting to take medications.
Rand said patients with a chronic illness are expected to accept that they need to take daily medications for the rest of their lives, even for illnesses like hypertension and dyslipidemia that may cause no noticeable symptoms.
Many of these people, she said, "may not really believe that [they] need this medication."
Rand also noted that terms like adherence and compliance reflect a top-down professional and authoritarian perspective that shifts blame for nonadherence to the patient.
She said studies examining text-message or telephone reminders, cash incentives, and other interventions have yielded positive results in some populations.
But, she emphasized, no reminder system will work for a patient who does not believe the medication is necessary to remain healthy.
Rand cautioned against the overreliance on "personal responsibility strategies" of adherence that punish patients in some way for failing to take medications as prescribed. She said these strategies don't consider individual patient factors and risk disproportionately penalizing vulnerable populations and increasing health care disparities.
Adherence initiatives. The National Consumers League last year launched a multimillion-dollar campaign to improve medication adherence. The Script Your Future campaign, whose partners include ASHP, other pharmacy and nonprofit organizations, FDA, and pharmaceutical companies, has online tools for patients and health care providers to help improve medication adherence.
Preliminary information obtained during the campaign's planning stages indicated that most patients do not understand their illnesses or the consequences of not taking medicines as prescribed. Survey data from the program suggest that compared with fully adherent patients, people who do not adhere to their medication regimen are less convinced of the importance of adherence and less likely to have had those consequences explained to them by a health care provider.
The campaign recommends that health care providers use direct, factual language to describe the consequences of nonadherence on the lives of patients and their families.
The Centers for Medicare and Medicaid Services, through its Center for Medicare and Medicaid Innovation, last year announced the availability of up to $1 billion in grants to support care delivery models that improve health outcomes and reduce health care costs. Nearly a quarter of the 81 programs selected this year for an award included a component to improve adherence to medication and treatment plans.
The National Institutes of Health on November 18, 2011, announced the availability of two-year research grants of up to $275,000 to support the development of novel, practical interventions to improve adherence to medication regimens. The application period closes in January 2014.