There is an ongoing debate about the purported benefits to improving medication adherence, with those that proclaim that just by improving adherence we will only see a measureable benefit in health-related outcomes, versus those like myself who say it’s just not that easy and that the opposite will occur in a significant number of instances. I say that because adverse effects from medications are a major barrier to adhering to medications, and by increasing the medication burden by improving adherence there is a resultant increased risk for adverse effects, hence poor adherence. Some studies suggest there was no measureable increase in the incidence of adverse medication effects when adherence was improved. However, the way one article was written, with 99.9% of the content studying improving adherence, and just one statement saying there was no measureable increase in the incidence of adverse effects, I became suspicious because I know better. Studying adverse events is a separate study by itself and I tend to believe they were not sensitive enough in their screening, nor was the study long enough to detect the appearance of adverse events, or perhaps they didn’t know what to look for. A quote by Dr. Michael Chisner puts this into perspective: “You see what you look for and recognize only what you know”. Interpretation: Many researchers don’t have the broad knowledge base to be able to detect ADEs hence do not report on their occurrence, and/or their bias was to study improvement in adherence.
In support of my argument, the increased incidence of ADEs by improving adherence is very well evidenced in research on HIV/AIDS medications, where improving adherence is critical and studied intensely. This body of research ALWAYS reports a higher incidence of ADEs with improving adherence, and ADEs are a barrier to adherence thereby lessening the beneficial effects from HIV/AIDS medications. In another publication, Critical Care Nurse, they reviewed barriers to adherence to heart failure medications stating “The adverse effects of medications contribute largely to non-adherence to a heart failure regimen.” They went on to state, “…because early recognition of adverse effects may help reduce difficulties in following medical prescriptions.” That being said, it speaks to the need to acknowledge that ADEs, whether real or perceived, must be considered as part of the overall plan in improving adherence. Things to consider are:
- Educate- Patient education about the most likely ADEs is important so they have realistic expectations and can report any symptoms suggestive of an ADE and therapy can either be altered, or they can be properly counseled that the adverse effects are transient. Proper patient education regarding what is contained in the drug monograph, which is required by law to be handed out, is critical since many people misinterpret the “Side Effects” listed and become afraid to take a medication. I have numerous phone calls regarding this scenario and find I need to explain and reassure them of the likelihood of experiencing adverse effects versus the benefit of adhering to the medication(s), this even after having counseled them in the pharmacy with no apparent reluctance or apprehension on their part.
- Monitor– 40% of ADEs are due to lack of monitoring. Put in place an appropriate monitoring plan in order to detect ADEs before they strike with a heavy hand. Once a person has a bad experience with a medication they become reluctant to take medications. Also, isn’t the goal to improve outcomes? So if we allow ADEs to occur and send someone to the hospital we have not achieved our goal.
- Listen to your patients! Self-reported adverse effects to medications are a reliable tool in screening for ADEs and should be used in every setting. However, the evidence suggests that either people don’t always report ADEs nor do practitioners listen and believe the patient when reporting ADEs. However, self-reporting of ADEs and changing of drug therapies by practitioners is shown to reduce the severity of possibly life-altering ADEs.
- Expand your knowledge base- There are so many unusual ADEs that one cannot possibly detect an ADE unless you have an expanded knowledge base. Remember Dr. Chisner!, “You see what you look for and recognize only what you know”. My first lesson was when a patient in a diabetes support group told me he couldn’t take a statin for his high cholesterol because it “caused memory loss”. I said that’s ridiculous. I then encouraged him to try another statin. His MD obliged, and the same thing happened, memory loss. I then went to the literature and verified the very real adverse effect from statins of memory loss. I learned two things, 1) listen, as stated above, and 2) I need to expand my knowledge base. Since then I have accumulated a vast amount of knowledge about unique and unexpected ADEs, especially in older adults who are 4 times more prone to experience an ADE.
- Simplify the drug regimen by moving to fewer times of the day to take medications, and pare down the number of medications by removing unnecessary medications and supplements. One of the most successful ways to improve adherence is to simplify the drug regimen.
- Screen for non-adherence- Understand that prescription drug databases are NOT reliable in measuring adherence. Many pharmacies offer an “auto-fill” service which automatically sends a patient’s prescriptions the same time every month. However, I must say this service has been a good screening tool since we have had a significant number of people say they have accumulated bottles of their medications and asked us to stop sending them, yet we send them every 30 days and they should not have an oversupply, unless of course they are not taking them as prescribed. That leads to the scenario of when MDs will instruct a patient to cut a dose in half, but not notify the pharmacy, nor does the patient. The prescription record then implies non-adherence since the patient is taking a lower dose. Many pharmacy computer systems can also screen for refill gaps. Use the technology to at least start the conversation.
Adhering to a well-designed drug regimen is probably one of our most cost effective forms of healthcare, yet getting to a well-designed drug regimen is not always accomplished, nor easy. And helping people adhere to their medication regimens requires eternal vigilance, and is not always successful, sometimes for very good reasons. We must also recognize that increased monitoring for ADEs needs to occur because any increase in drug burden, the number of doses and/or drugs taken each day, is directly correlated with an increased incidence of adverse effects.
Updated Oct. 3, 2012: Since posting this subject I have had discussions with an experienced hospital pharmacy director and researching MD that always consider community-based adherence when a person is admitted to the hospital since poor adherers will likely suffer from an adverse drug event from the increased drug burden as a direct result of improved adherence. A thoughtful review of a persons medication regimen must occur in order to make changes where otherwise could result in harm. An example might be in someone who takes 50% of their warfarin doses and then is administered the drug at a rate of 100% of the time. The result is obvious.
Updated Oct. 21, 2012- An excellent example of where non-adherence is not confirmed and leads to an adverse drug event can be found at this link to the Annals of Long Term Care, where an older gentleman is non-adherent to his digoxin, ends up in the hospital after a fall for hip fixation, has his digoxin dose doubled due to a serum level <0.1ng/ml, and then is discharged to a nursing home. His fourth day in the nursing home he has a fall, and further workup reveals a digoxin level of 3.5ng/ml, among other things related to his medications and ADEs. There you have it!