PRACTICE POINTS

• Establishing a good rapport with your patients will improve patient adherence.
• If the condition is chronic, say so, but emphasize the reality that most chronic conditions wax and wane over time.
• Keep in mind that patients remember or understand as little as half of what their physicians tell them.
• Try to prescribe a treatment regimen that has few side effects and is easy to follow, nonaddicting, and inexpensive.
• Counsel patients about the importance of full adherence, and provide written instructions to enhance it.

The following hypothetical case is a good example of issues often encountered in the acute care setting.

Last week, you treated Mr Abernathy, an otherwise healthy 40-yearold accountant, for low back pain. After a brief examination and screening for any red flags, you explained that his problem appeared to be acute pain caused by muscle strain. In deciding on the best management, you relied on expert evidence¹:

• Bed rest is unnecessary and may actually lead to further debilitation.
• Nonsteroidal anti-inflammatory drugs or acetaminophen are appropriate analgesic medications.
• Skeletal muscle relaxants are also appropriate interventions.

You prescribed ibuprofen, 400 mg every 4 to 6 hours as needed, for pain and a skeletal muscle relaxant and handed him a sheet of paper describing some exercises. You also told him to gradually increase his level of activity. Today, Mr Abernathy calls complaining of continued back pain. A few pointed questions reveal that your careful treatment plan was a waste of time; he languished in bed all week and took medication sporadically for only 3 days, if that.

What Went Wrong?

Mr Abernathy made independent decisions based on what he believed was best for him. Although patients are free to ignore physicians' advice, following this evidence-based treatment plan could have saved Mr Abernathy money, time, and most important, pain. How can you help patients like Mr Abernathy adhere to your treatment plan? A good starting strategy is outlined in Table 1.

Unfortunately, medication adherence is low, regardless of the condition or problem studied. Patient compliance with nonpharmacologic modalities is also dismal. Typical rates of adherence hover at about 50%, and range from total nonadherence to overadherence. In 1992, the National Pharmaceutical Council reported that the cost of noncompliance in the United States exceeded $100 billion.² More recent estimates place it at $175 billion.³ This number includes deaths, hospitalizations, nursing home admissions, and the 20 million lost work days that cost $1.5 billion in earnings and $50 billion in productivity.⁴

Most adherence studies address chronic conditions. The literature on adherence among patients with acute conditions is surprisingly sparse,⁵ but based on anecdotal evidence and our clinical experience, such patients may also ignore sound medical advice.

Adherence Versus Compliance

Called "compliance" for decades, adherence is the extent to which patients follow the instructions you provide when prescribing treatments.⁵ Compliance—the act of complying with a wish, request, or an instruction—implies an asymmetrical relationship in which the patient is expected to acquiesce to the prescriber's directives.⁶ Using the terms "adherence" and "nonadherence," we can avoid the implication that the physician is judging the patient for failing to follow directions, introduce an element of equality in the physician-patient relationship, and reinforce patients' right to choose not to follow the advice of a health professional.

Although it may seem natural that adherence challenges some socioeconomic, gender, age, or lifestyle groups more than others, a relationship between medication nonadherence and specific demographic factors has yet to be established.

Types of Nonadherence

Treatment nonadherence is sorted into 5 categories, which are not exclusive to medication, since other treatments, such as exercise, are also fraught with nonadherence.³

Hesitance to initiate therapy. This includes both a patient's unwillingness to visit a physician when ill, and the patient's failure to begin a prescribed regimen.

Skipped doses covers situations where patients legitimately forget to take their medication or choose to skip doses because it is inconvenient (eg, the medication must be taken with food, and the patient is not hungry).

Therapy discontinuation. Stopping treatment often occurs when patients fail to understand how or how soon a medication should work (ie, they stop taking a drug when symptoms resolve or they do not feel better when they think they should, thus placing themselves at risk of recurrence). Acommon example is the patient who stops taking penicillin because his strep throat feels better.

Dose self-adjustment. Decreasing or even doubling doses without first consulting the prescriber is a common form of nonadherence. Taking more medication than is prescribed is overadherence or overcompliance (a subcategory of nonadherence).

Inappropriate drug administration. This occurs when patients ignore specific guidelines and instructions, or misuse, and sometimes abuse, their prescribed medication.

Barriers to Patient Adherence

Barriers to patient adherence with any treatment regimen include, but are not limited to, several variables.

Patients'independent assessment of the risk and benefit. Patients may perceive the treatment benefit to be small compared with its cost, unless physicians communicate very clearly with them or anticipate their conflicting beliefs and work around them.

Potential side effects. Often patients worry about sedation, constipation, sexual problems, or other adverse events. When the prescribed medication is needed on a long-term basis, side effects can be a significant impediment to adherence. When treating both chronic and acute conditions, unwanted drowsiness sometimes prevents an individual from performing everyday activities, such as driving or working. Sometimes, however, physicians may want to exploit sedation-inducing side effects to help patients sleep. Knowing the drugs in a class that are most likely and least likely to cause drowsiness—for example, cyclobenzaprine (Flexeril) and metaxalone (Skelaxin), respectively, among the skeletal muscle relaxants—can save time.

Cost. Treatment costs and prescriptions can represent a significant burden for uninsured or marginally insured individuals. In a survey of 875 older adults, 19% said they had cut back on their use of medications in the past 12 months because of cost.⁷ Alternatively, patients who have prescription drug riders may prefer a prescription drug to an over-the-counter medication as a cost-avoidance measure.

Regimen complexity. Simple, easily remembered medication regimens are naturally preferred by patients, hence the rise in once-daily, transdermal, or other convenient dosing formulations for chronic drug therapy. In acute conditions, the patient's discomfort may serve as a subliminal adherence signal. In our patient, Mr Abernathy, for example, pain or spasm related to his low back pain can remind him to take his medications.

Fear of addiction. Believing that all pain medications are addictive, many patients avoid taking them or alter (ie, reduce) the dose. In a survey of 324 patients with chronic illnesses, more than one third had significant concerns about prescribed medications because of their beliefs concerning the risk of dependence or the long-term effects.⁸ That study showed that the greater the patient's concerns, the lower the adherence.⁸ Some patients may increase doses, whereas drug seekers may try to manipulate physicians into prescribing addictive substances for secondary gain.

Addressing Lack of Adherence

Lack of adherence frustrates physicians and forestalls optimal outcomes. Some researchers suggest that physicians should take a biopsychosocial approach, especially when patients are in pain. This involves creating a treatment plan based on the patient's physical symptoms, emotional readiness to carry out the prescribed regimen, and social or life factors that might interfere with adherence. Physicians may better understand the importance of patients' beliefs about a prescribed medication by considering the Health Belief Model, which proposes that patients will always weigh a treatment's costs against its benefits and will only proceed if the benefits outweigh the risks.⁶ Apatient's beliefs about prescribed medications, including whether the drug is necessary, and concerns about dependence or long-term effects have been shown to be stronger predictors of adherence than clinical and sociodemographic characteristics.⁸

Consider the Individual Patient

Physicians can improve adherence if they start by establishing a good rapport with the patient. Dissatisfaction with a physician's interpersonal manner has been linked to decreased medication adherence.⁹

When treating a patient with a condition that is chronic or recurring, ask what has worked in the past.¹⁰ If a drug was successful before, it is likely to work again. Based on past treatment, sometimes patients will adamantly insist that they need an addictive medication or a poorly targeted drug that introduces additional, nontherapeutic side effects. Our example of low back pain is ideal here, because occasionally patients will complain of low back pain or malinger with this diagnosis to obtain certain drugs. Physicians who prefer to use a different medication, perhaps because it has less potential for addiction or is less sedating, should take a few minutes to voice their objection to the particular drug the patient wants, stress the new drug's similarities to the old one, and explain why the new agent is better. Table 2 lists additional factors that may affect adherence.

The main message is that there is no one-size-fits-all treatment. Each patient is unique, and the physician must match the treatment to the individual patient.

Providing a Familiar Context

People tend to learn best when information is presented in a familiar context.⁵ This is particularly important for patients with acute conditions. They will have questions like, "How long will this last?" or "Is this a permanent condition?" They will also want to know how the treatment will facilitate or delay their return to everyday activities. Honesty is essential. If the condition is chronic, say so, but emphasize the reality that most chronic conditions wax and wane over time. For acute conditions, such as low back pain, you can assure the patient that in almost all cases, the problem is short-term, and treatment will help. Most important, educate the patient about the risks and benefits of all parts of the treatment plan,⁷ emphasizing the need to adhere even if the patient does not think she is improving.

Keep in mind that patients remember or understand as little as half of what their physicians tell them.¹¹ Yet research suggests that primary care physicians attempt to determine if their patients can recall and comprehend the new concepts they have introduced only between 12% and 20% of the time.¹¹

Physicians might consider providing "decision aids" to patients. Decision aids are packets containing detailed information on benefits and risks along with simple in-depth explanations about the likelihood of the expected benefits and risks.¹⁰ Patients should understand each medication's purpose and how it works (eg, "This prescription will reduce spasms, and it may take 3 days before you really feel the effects").¹² Research has shown that patients are more likely to adhere to a treatment regimen when the possible adverse effects have been outlined and defined.^10,13

In one study, 252 patients with osteoarthritis of the hip or knee were randomized to usual care or to usual care plus interaction with a computerized education program describing their disease, the prescribed medication, its side effects, and its appropriate use. The intervention group was more adherent with the prescribed medication (P <.029) and was also more knowledgeable, had more realistic expectations of the drug's efficacy, and felt it was easier to adhere to the treatment (all P <.05) compared with the control group.¹³ Finally, physicians should consider offering choices or negotiating a treatment plan, for instance, saying, "These are the options. Which do you think would work best for you and your lifestyle?"

Simplifying Regimens

The ideal regimen should have few side effects and be easy to follow, nonaddicting, and inexpensive. It should also be simple. But few treatments meet all these criteria. In the case of pain, most analgesics and muscle relaxants require several doses during the day and may produce side effects. In addition, some of these medications are addicting. So regimen planning can be a challenge.

When dealing with patients who have comorbid conditions and who are taking other medications, try to avoid having them take medications at odd hours or at inconvenient times. Schedule all doses concurrently if possible. Try to tie doses to convenient reminders, such as when the patient gets up in the morning; with breakfast, lunch, or dinner; or at bedtime. Keep in mind that a prescription that says, "Take x tablets when needed" is neither simple nor prudent, because patients vary greatly in their perception of when a medication is needed. Increasingly, experts recommend scheduling pain medication.¹ Tell patients that it is not wise to wait for pain or spasm to trigger a dose.

Decreasing Dose Frequency

For Mr Abernathy, simplification of his shortterm treatments could improve his adherence and treatment outcome. This means decreasing either the number of daily doses or the number of units per dose. Patients are more likely to take 1 tablet containing 60 mg than 2 tablets of 30 mg. According to one large telephone survey, 8 of 10 Americans admit they would be more likely to remember to take a medication if they had to take it only once a day.¹⁴

Treatment Adherence Issues in Acute Conditions

In a meta-analysis of 8 studies involving 11,485 prescriptions, patients were adherent with once-daily medications about 94% of the time compared with 83% for drugs taken more than once a day.¹⁵ Another meta-analysis of 76 studies confirmed the inverse relationship between adherence and number of doses, finding the following average compliance rates¹⁶:

79% with 1 daily dose
69% with 2 daily doses
65% with 3 daily doses
51% with 4 daily doses.

On the other hand, skipping a once-daily or twicedaily dosed medication reduces adherence rates significantly compared with more frequently dosed drugs. A patient who skips 1 of 2 daily doses misses fully half of his medication; in someone who skips 1 of 3 daily doses, the therapeutic gap is narrower.

Medication Labeling

Precise, concise labeling may greatly increase the likelihood of adherence. In a study of 70 patients with an acute infectious disease who were prescribed short-term antibiotic therapy, more than 99% of patients were adherent with the prescribed medication, yet only about one third took the medication within a 1-hour interval of the time recommended for optimal efficacy of a twice-daily dosed drug.¹⁷ Labeling with specific times can help patients remember to take the medication.¹⁸ For the low back pain patient, for example, scheduling doses rather than allowing as-needed administration can help stop the cycle of pain. In the same way, scheduling doses for 7 ^AM, 3 ^PM, and 10 ^PM rather than every 6 hours as needed can be helpful.

Unit-dose packaging, such as that used for oral contraceptives or some antibiotic regimens, eliminates the need for patients to remember how each dose of medication should be taken.³ Manufacturing unit-of-use packaging, however, is expensive, and many drugs are not currently available in this form. A study of 304 Medicaid beneficiaries showed that unit-dose packaging significantly increased refill adherence compared with standard care; supplementing unit-of-use packaging with a mailed refill reminder improved adherence further.¹⁹

Thus, since it may improve adherence and treatment outcomes, such packaging may become an attractive marketing strategy for drug manufacturers. Until then, it often helps to be familiar with adherence aids that you can suggest to the patient, such as medication boxes that can be used to separate doses by day and time. One study showed that 89% of patients with Helicobacter pylori infection who were given a medication calendar and mini-pillbox along with written and oral medication counseling and a follow-up telephone call took more than 90% of prescribed medications, compared with 67% of those who only received the medications without further adherence-enhancing interventions.²⁰

Patient Education

A multifaceted approach to patient education promotes adherence and improves outcomes. When possible, information should be provided in the patient's native language. The National Institutes of Health maintains a Web site (www.nlm.nih.gov/medlineplus/ backpain.html) that has links to several sites that offer excellent patient education aids.

Physicians should communicate information verbally and then reinforce it with written information (leaflets or pamphlets).¹³ A recent study showed that when verbal instructions were supplemented with written instructions, patients with acute sore throat were much more likely to adhere to the recommended antibiotic treatment regimen.²¹ A systematic review of randomized, controlled trials found only 3 studies that investigated interventions for enhancing adherence with short-term treatments. All 3 studies involved interventions for acute infection. Although the studies investigating the role of information about side effects or treatment in general showed no impact on adherence, another study found that counseling the patient about the importance of full adherence and reinforcing the counseling with written instructions enhanced adherence.²²

Pointing to written information, or even highlighting important points with a bright-colored marker as you provide a verbal explanation, reinforces that patients will have an information source to refer to when they leave the office. Writing on the prescription, "Please counsel patient to take full doses as scheduled," will ensure that the pharmacist further reinforces your directions to the patient.

Conclusion

Open, clear communication about a patient's situation can greatly increase adherence. The keys to improving adherence are 2-fold: involving the patient in developing a treatment plan and asking the patient to identify barriers to the treatment goals you have set. It is also important to welcome questions and dispel myths about the addiction potential or side effects of medications.

SELF-ASSESSMENT TEST

1. Which of the following is NOT an example of medication nonadherence?

1. Hesitating to visit a physician when ill
2. Legitimately forgetting to take a dose
3. Seeking a second opinion
4. Stopping a medication earlier than prescribed because symptoms resolve

2. Which of these approaches is least likely to encourage adherence?

1. Recommending over-the-counter drugs to patients with prescription drug riders
2. Avoiding opioid analgesics in a patient with severe pain who fears addiction
3. Exploring the patient's ability to pay for a drug
4. Asking the patient what has worked in the past

3. Which of these would be least likely to encourage adherence to recommended therapy in a patient with an acute condition?

1. Tell the patient that the condition will probably be short-term
2. Minimize the use of medical jargon
3. Avoid talking about potential side effects
4. Tell the patient that your treatment plan is based on research

4. All these statements about adherence to medications are true, except:

1. Having fewer daily doses minimizes the therapeutic impact of a skipped dose
2. When possible, schedule concurrent dosing for patients who take medications for comorbid conditions
3. It is better to schedule pain medication for specific times rather than as needed
4. Unit-of-use packaging can improve adherence

5. Which of these patient characteristics is least likely to affect adherence?

1. Gender
2. Cultural background
3. Worker's compensation status
4. Job status

(Answers at end of reference list)