Last week I suggested that older people may have too many prescriptions. It turns out that it may not be as big a problem as I thought. It was in 2003 that the World Health Organization first looked at the issue of “Medical Adherence”. Were patients following the prescriptions and protocols given to them by their doctors? The results were startling. In China only 43% of patients took their hypertension drugs. In the US the number was 51% and in Gambia 27%. Even though these drugs have been proven to cut heart attacks and strokes. Around the world only between 40% and 70% took their anti-depression drugs. The WHO argued that adherence was the biggest opportunity to improve world health.

The pattern was the same. Adherence was high initially but fell off quickly. Within 6 months to 1 year after having been prescribed statins, approximately 25% to 50% of patients stop taking them. At the end of 2 years only 25% of people are still taking them. Non-adherence extends beyond taking the pills. People do not do what the doctor says. They do not attend their appointment. They do not lose weight. They do not stop smoking or drinking. They carry on using recreational drugs. They do not adapt their diet as recommended. They do not change their sexual habits.

The impact can be profound. If we don’t take the drug we won’t get better. If we don’t take the drug and don’t tell the doctor, they will think it is not working. The result is that we may end up in hospital. We may end up being prescribed more pills. It is estimated that the US spends $600BN a year on prescriptions. One conservative estimate suggests that a third of this is wasted. No one knows the cost on the rest of the health services.

Don’t blame the patient.

It has become clear that this is a systemic problem. It is not simply a “bad” patient. The doctor and the system have a role to play. There are simple economic factors in many places. These even include affluent societies. People cannot afford the drugs they have been prescribed. This is especially the case for older people with multiple chronic diseases. Apart from that there are no clear socio-economic factors. Less educated and poorer people are less likely to comply. But is this the underlying cause? There is no clear evidence that age per se predicts “the takers” and the “non-takers”. Medical Literacy is an issue, but it is part of a broader psychological picture.

Why don’t people take their pills?

We can just forget. Beyond that there are three things needed to ensure compliance. We need the information in a way that we can understand it. We need the motivation, and we need the skills to manage a medical regime. Information is much more then the instructions written on the box. We need the doctor to be given the time and then take it to explain. We need to know why we need to take a medicine. Why the doctor has chosen a particular medicine. We need to understand how it works and what the side effects can be. We need to know how to spot a side-effect and how the doctor would stop it. We need to know when and how to take the medicine. We need to know when to stop taking it. A recent study looked at these prescription interviews. 65% of doctors missed out at least one of these messages. Other studies have used pharmacists. When they take the time to explain, adherence jumps up. Unfortunately, communication is two-way. Most patients only can recall half of what the doctor said during any given appointment.

I was very fortunate not to have taken a regular pill until three years ago. I wonder whether my doctor realized the impact of telling me I would be taking the drug for “the rest of my life”. It was a life sentence. It meant I was not going to get better. It meant that I was getting old. It triggered again my “need for control”. That desire we all have, to be and feel in control. Being “forced” to take the drug took control away from me. No wonder people stop taking the drug or experiment with the dosage.

We all have a different view of who controls our lives. Some believe that they are in control. Others that” powerful others” control their destiny. Finally, a different group believe that life is all about random chance. Each of these three will react differently to a complex medical regime. Each will have a different motivation to conform.

Fixing the Problem

All over the world studies are being done to try to fix the problem. In Newsletter # 120 ( “A Country for All Ages”) I described an education program in Singapore. It was for older citizens and dealt with how to remain healthy. People need the knowledge and skills to mange their medication. It is worse because it is the older people that have the most complex regimes.

Awareness amongst doctors can help. If a patient needs a new drug, does it fit with their lifestyle? If it needs to be taken three times per day, will it work in their routine? There may be a drug that is slightly less effective. It may be a better fit because it only needs to be taken twice a day. In fact, it may be more effective - the patient will continue to take it instead of dropping it after 6 months.

We can create systems that remind us to take our pills. The doctors can place an app on our smart phone. That same phone can be used to monitor our blood pressure. If it doesn’t drop, we are either not taking the new drug or it is not working. There is a particular problem with preventative medicines. If something makes us feel better, we will take it. If it prevents something we are less successful. We are better off, in that case, if there is a concrete impact like blood pressure, we can track.

Pills that combine drugs seem to be an impossible dream. Why not one combined customized pill a day? Why not “delayed release” pills that can last a week? The competitive nature of the drug industry makes such things impossible. Or is it the doctors and the system that insists on the latest new drug and ignores whether it is taken?

A recent Surgeon General of the USA put it this way:

Drugs don’t work if patients don’t take them