DEFINITION: (INTENSITY OF DRUG USE)
Medication adherence is defined as the degree to which persons or patients behavior
corresponds with agreed recommendations from a health care provider.
It refers to the intensity of drug use during the duration of therapy which has grater
effects on health than improvements in specified medical therapy.
TREATMENT > ADHERENCE > OUTCOMES
INTRODUCTION:
Adherence to therapies is primary determinant of treatment success. Failure to
adherence affects not only the patient but also the health care system.
Adherence can also be called as compliance or concordance. Here compliance means
the extent to which a patient behavior matches the prescriber’s advice.
Medication non-adherence in patients leads to the substantial worsening of disease, death
and increased health care costs.
It can have negative consequences not only on patients but also pharmacists, physicians
and even medical researchers who are working to establish the value of medication on the
target population.
Adherence rates are typically higher among the patients with acute conditions as
compared against those with chronic conditions.
Hence helping the people take their medicine appropriately would be a better
achievement to avoid higher risk of
Severe disease relapses.
Antibiotic resistance.
Prevent hospitalizations.
Prevent lower quality life.
Avoid wastage of medication.
TYPES OF MEDICATION NON-ADHERENCES:
The different types of medication non-adherences are as follows:
This is also called as non fulfillment adherence. Here the medical practioners write the
prescription but the medication is never filled or dispensed, since the patients do not take them to
the pharmacy and some others fail to pick up the medication from pharmacy assuming that.
They have recovered from disease or suffering.
Having the same medication at home.
NON PERSISTANCE: (OVER ALL DURATION)
In this type of non adherence patients decide to stop a medication after starting it without
being advised by a health care professional.
It happens when patients and providers have miscommunication about therapeutic plans
like
Poor administration techniques.
Eg: Metered dose inhalations.
Cost of the medication.
NON – CONFORMING:
This is the third type and in this type it includes a variety of ways in which medications
are not taken as prescribed. The behavior can range from
Errors of dosage.
Errors in the time of administration.
Pre matured discontinuation.
Taking medication more than prescribed.
FACTORS AFFECTING MEDICATION ADHERENCE:
Measurement of medication adherence is challenging because adherence is an individual
patient behavior.
The following are the factors that are majorly associated with non compliance which
include
Subjective measurements.
Objective measurements.
Bio chemical measurements.
SUBJECTIVE MEASUREMENTS:
Non adherence varies between and within individuals as well as across time,
recommended behaviors, diseases. It also varies with patient age groups (pediatrics and
geriatrics) due to their dependence on adult care givers. They include
DISEASES:
The nature of patient’s illness may in some cases or circumstances contribute to
non compliance.
In patients with psychiatric disorders, schizophrenia (psychotic disorder),
hypertension, hyper cholesterolemia which are not often associated with
symptoms are more said to be non compliers.
It might be anticipated that patients experiencing increased disability will
motivate compliance in most of the cases.
PATIENT/HEALTH CARE PROFESSIONALS INTERACTION:
The patient physician interaction has been described as the negotiation between
two active and equal participants that include elements of respect, positive
attitude, information, translation, feedback, patient response etc.
Respect for patient and realistic appraisal for circumstances of individual patients
is essential if therapeutic goals are to be achieved.
FAILURE TO COMPRAHEND THE IMPORTANCE OF THERAPY:
The importance of drug therapy and the potential consequences if the medication is not
used according to instructions is a major factor concerned.
Patients should know the exact benefits and expectations with respect to drug therapy.
If this does not meet these expectations they are more likely to become no complaint.
POOR UNDERSTANDING OF INSTRUCTIONS:
Patients with low literacy may have difficulty in understanding the instructions which
ultimately result in decreased adherence and poor medication management.
Gender, personality and cultural factors may also influence adherence compliance rates.
COST OF THE MEDICATION:
Non compliance may occur with the use of drugs that have relatively low cost or high
cost.
The expense involved has been cited by some patients as a reason for not having
prescriptions dispensed at all. Where as in other cases the medication is taken less
frequently that intended or prematurely discontinued.
ASYMPTOMATIC OR SYMPTOM SUBSIDES:
It is difficult to convince a patient the value of drug therapy when patient has not
experienced symptoms prior to the initiation of the therapy.
OBJECTIVE MEASUREMENTS:
MULTIPLE DRUG THERAPY:
Non adherence can occur when medication regimen is complex which could include
improper timing of drug administration or administration of number of medicines at
frequent intervals or unusual times during the days.
Secondly some elderly patients may experience lapses of memory that make non
compliance more likely.
Thirdly the similarity of appearance of certain drugs may contribute confusion which
will also lead to non compliance.
ROUTE OF ADMINISTRATION/FREQUENCY OF ADMINISTRATIONS:
The route of administration in many times also influences the non-compliance towards
the medication since they may be at times complicated or dependent.
The administration frequency also disturbs normal routine work schedule with in many cases
patients will forget not want to be in convinced or to embarrass to do so.
The attitude of patients should be anticipated towards their illness.
DURATION OF THERAPY:
The potential for non compliance is grater when treatment period is long.
Non compliance should be anticipated in patients with chronic disorders
especially anticipated in patients with chronic disorders especially if
discontinuation of therapy is not likely to be associated.
ADVERSE EVENTS:
The development of unpleasant effects of a drug is a likely deterrent to
compliance.
Nearly 40% of the patients have experienced some form of side effect during
medication use, and out of this 40% people nearly 50%stopped taking the
medication as a result of side effects.
Eg: Sexual dysfunction, nausea, vomiting, hair loss, headache etc.
TASTE OF THE MEDICATION:
This type of non compliance is seen majorly in children who take especially oral
liquids.
Pharmacists should also have a regard towards size of the medication, wrong
route of administration etc.
Eg: one patient suspected death to chewing of diltiazem extended release
capsules.
BIOCHEMICAL ADHERENCE:
Biochemical measurements obtained by adding a nontoxic marker to medication
and detecting its presence in blood or urine or in measurement of serum drug
levels also shown patients non compliance towards the therapy.
ROLE OF PHARMACIST IN IMPROVING MEDICATION ADHERENCE:
The effectiveness of the treatment depends on both the efficacy of medication and patient
adherence to the therapeutic regimes.
Patients, health care providers, health care systems all have a role to improve medication
adherence.
A single method cannot improve medication adherence instead a combination of various
adherence techniques should be implemented to improve patient’s adherence to their
prescribed treatments.
The role of pharmacist in improving medication adherence are
DEVELOPMENT OF TREATMENT PLAN:
The prescription can be used as the organizing instrument of instructions. The
more complex the treatment regimen the greater is the risk of non compliance and
this must be recognized in development of treatment plan.
The treatment plan should be individualized on the basis of patient needs, and if
possible he should also participate in decisions regarding therapeutic regimen.
Instructions such as “as directed” or any other directions which create
unnecessary confusion should be avoided.
Treatment medication should not avoid patient’s daily routine works.
PATIENT EDUCATION 🙁 INFORMATION AND EDUCATION (ENDS IN
DECESSION MAKING)
Education is the best way to improve compliance. It reduces the communication
gap which has serious impacts on public health.
The main goal is to provide information that patient is able to understand and use.
The anticipated benefits should be explained properly.
Patients should be asked to repeat the instructions to know the level of
understanding.
ORAL COMMUNICATION/COUNSELING THE PATIENT:
It can be done orally or in written formats. It gives the patient an opportunity to
raise questions about the therapy such that it increases rate of compliance.
Address the key information about the drugs (what, why, when, how, how long).
Inform the common side effects and those that patients necessarily know.
USING MEDICATION ADHERENCE IMPROVING KITS:
Provide medication calendars or schedules that specify the time to take
medications.
To improve compliance drug cards, medication charts or information leaflets or
specific packing such as pill boxes, unit of use packing and special containers
indicating the time of doses are used.
PROVIDING BEHAVIORAL SUPPORT:
Collaborate with the patients especially geriatrics and pediatrics to incorporate the
medication regimen into his/her daily regimen.
NOVEL DOSAGE SYSTEMS:
Motivating the patients to use now dosage forms of certain drugs which are longer
acting, controlled release can also facilitate the compliance.
The use of transversal delivery systems has a great impact in developing
the adherence.
MONITORING THERAPY:
The important things involved in these are
SELF MONITORING:
Patients should be apprised of the importance of monitoring their own
treatment regimen and respond to the parameters personally.
NOTE: “If your medicine is not working……..it may not be the medicine at
all. It could be you”.
PHARMACIST MONITORING:
Improved compliance can also be done by pharmacists by follow ups with
telephone, mailed refill reminders.
By brown bag programs etc.
Identify difficulties and barriers related to adherence and assess.
Checking up the effectiveness and informing physicians etc.
COMPLIANCE PACKING:
The manner in which medication is packed also has an influence on the
patient compliance.
The use of child resistant containers for patients having specific diseases
likes RA; Parkinsonism, skin allergies has shown a great impact on
compliance. Hence this should be changed to improve compliance.
CONTROLLED THERAPY:
Hospitalized patients be given the responsibility for self medication prior to
their discharge will also result in better compliance.
The suggested technique avoids non compliance since professionals involved
can identify problems that create inconvenience can be sorted out and helps
also for patients with barriers