The goal of modern healthcare is essentially a positive lifestyle change. Doctors want to encourage effective behavior change to improve the health and quality of life for their patients. Studies show that a lack of compliance with prescribed drug therapy and other treatments contribute significantly to poor health outcomes.
Doctors know that patients fare better when they understand their prescriptions and follow their treatment instructions. Failure to do so often results is complications, readmissions to hospital care, poor health outcomes, and increased costs.
Clinicians, healthcare stakeholders, and payees (like insurance companies and governments) see medication adherence as a burdensome problem. There is mounting evidence from various government and private studies that non-adherence is pervasive and is directly proportional to adverse outcomes and higher costs of care. Unfortunately, there are several barriers to medication adherence, like with other complex health behaviors, such as weight loss or smoking cessation.
Patients are expected to understand how to navigate the systems of care from which they seek treatment. This may include everything from their physician’s office, to the insurance forms and medical questionnaires, pharmacies, hospitals, home health services, alternative medicines, and other health-related venues. Patients must be able to read, understand, and make reasonable decisions based on the information they get and receive from various participants.
Their active communication and personal advocacy is vitally important, yet often patients don’t ask adequate questions (or even know what to ask), and as a result doctors can’t effectively share the information they need. With each new venue and each new treatment the level of complication increases, placing them at risk for errors that can result in adverse health outcomes.
Medication adherence typically refers to making sure patients take their medications as prescribed and for as long as the treatment dictates. Therefore, medication adherence behavior is typically thought of through two main concepts—adherence and persistence. Adherence refers to the amount of drug use during the duration of the prescribed treatment, and persistence refers to the overall duration of drug therapy.
One problem in assessing the adherence and persistence of patients’ prescribed medication treatment is the lack of standardized measurement in routine clinical practice. Prescribing and consulting physicians may not follow-up adequately about the amount and length of drug therapies during subsequent visits, leaving gaps in their knowledge of the treatment regimen.
Recognizing the need for more standardized follow through, one study called medication adherence the “next frontier in quality improvement.” The issue is one of the most pressing health care challenges in America with room for gains in both health outcomes and reduced healthcare costs for all stakeholders.
Where medication therapy is concerned, too much can harm health outcomes the same as too little. According to recent reports, prescription drug misuse in America is a growing problem. The Centers for Disease Control and Prevention has even declared prescription drug abuse an epidemic in America. America has only five percent of the world’s population yet consumes 75 percent of the world’s prescription drugs.
Painkillers, tranquilizers, and stimulants are the most commonly abused prescription drugs.
The majority of prescription drugs that are misused are obtained free from a friend or relative. The ease of obtaining the medications, combined with a lower negative stigma, the fact that the drugs are not illegal drugs, and the decreased risk of criminalization all contribute to a pervasive misuse of prescription medications, particularly among teenagers.
A recent article in the Journal of the American Medical Association advocates for more training for medical staff, better tracking of medications, and improvements in diagnostic accuracy for the underlying causes of medication non-adherence. Research focused on medication misuse—whether too much or too little—suggests that clinicians often fail to accurately predict how closely patients stick to their prescription therapy.
In 2010, a health reform law included new incentives for Medicare managed-care plans to seek greater medication adherence, in order to bring the issue into focus. Bonuses for Medicare managed-care plans are now tied to the percentage of enrollees who frequently fill prescriptions. In other words, medication adherence now has a financial spotlight.
In 2010, the U.S. Drug Enforcement Agency’s Automation of Reports and Consolidated Orders System (ARCOS) reported that 90 of the top 100 oxycodone purchasing physicians in the nation were located in Florida.
According to Florida Attorney General Pam Bondi, factors leading to the proliferation of “pill mills” in Florida include a weak regulatory oversight of pain management facility practices, limited oversight of physician dispensing habits, and no statewide Prescription Drug Monitoring Program (PDMP).
The Florida Legislature passed measures in 2011 to give authorities more oversight of Pain Management Clinic practices, tracking, and reporting. The regulations have been used to close clinics deemed to be operating outside the scope of the prevailing standards of medical practice in pain management. The efforts are part of several initiatives to combat prescription drug overdoses and misuse in Florida.
Across the nation there seems to be a growing recognition of the need to change behavior in order to help patients achieve healthy lifestyles. Medication management is just one part of that lifestyle approach. A key strategy for the medical professional is to seek opportunities for education to recognize the signs and symptoms of prescription misuse (whether too little or too much), and to be informed about the laws and regulations of administering and tracking substances use.
Screening for prescription drug use can be incorporated into routine medical visits by asking about substance abuse history, current prescription and OTC use, and reasons for use. By engaging in those conversations, and making sure that patients understand the importance of appropriate medication adherence, doctors are helping to increase health outcomes and decrease healthcare expenses for all involved.
Commentary from Sergio B. Seoane, MD – Contributing Editor:
A significant reason for patients not adhering to their medication regimen is a lack of understanding. The single most important determination of the health of a population is the level of education of the population. If patients do not understand why medications prolong life and decrease illness then they will not take medications.
There is also a disturbing trend in American culture and society that reflects a suspicion of science—a distrust of science. This has led to a growth in “alternative medicine.” Much of alternative medicine is based on fraud, fear, suspicion, and deliberate misuse of information.
Ultimately, a well-informed and well educated population is the best guarantee of good health and long life.
by MICHAEL “JAMIE” SELF, Ed.D.
reviewed by Sergio B. Seoane, MD