Corinn Martineau, PharmD, BCACP, CDOE

Former US Surgeon General C. Everett Koop, MD, once stated something that is still powerful and relevant today: “Drugs don’t work in patients who don’t take them.”  

In the United States, the consumption and spend on prescription drugs continue to increase, with 2018 data showing 5.8 billion prescriptions dispensed at a cost of $344 billion. Of those prescriptions, two-thirds were intended for chronic diseases.

 With targeted medication therapy accounting for up to 80% of chronic disease management, the incredible missed return on those prescriptions is a sobering event, given that an estimated 30% to 50% of medications are not taken as prescribed.

 Research into this lost value demonstrated that in 2016, the cost burden of nonoptimized medication therapy in the United States ranged from $495.3 billion to $672.7 billion. To make this more personal and real, the authors estimated that this accounted for 275,689 deaths per year.3 Many advances in behavioral science, packaging solutions, and technology, along with construction of predictive risk assessment tools, have attempted to improve medication adherence. Below is a review of some of those advancements and interventions, some very high-tech touch and some high touch. Note, however, that a number of strategies have not been robustly studied for effectiveness; thus, the value of the given intervention or the combination of interventions is not known. Additionally, for more technologically advanced solutions, the industry needs to focus on the individual’s ability to provide the appropriate and necessary human interface to leverage the proposed value of the automation.

The concept of aligning a patient’s medication refills makes a lot of sense, as it easily reduces some barriers and burdens. Studies have produced positive results, with a recent published article demonstrating that synchronization lowered emergency department visits and hospitalizations in a patient population with cardiovascular disease.

 Maximizing the use of this strategy requires ongoing changes in insurance payment models, with some success already seen through state legislation advocacy. 

MEDICATION PACKAGING AND REMINDER TECHNOLOGIES 

Multimed packaging has moved beyond the traditional 7-day pillbox. Bottle caps and pillboxes have integrated Bluetooth technology surveillance to relay data on when the containers were opened back to providers. Other devices snap onto inhalers to measure use, and still others have integrated alarms to remind patients to take their medications. Even medication dispensers can be programmed to prevent a patient from taking a medication late or too soon. Additionally, a growing movement is focused on dispensing medications in multimed packaging, sometimes referred to as adherence packaging. The upside of these packaging options is that they are very convenient and organized for patients up front. However, providers should exercise caution and implement processes to prevent errors when medication treatment regimens change. In short, many medication reminder technologies are available, and a simple internet search will yield results for many devices and phone and tablet applications.  

Likely the most advanced approach to tracking the actual consumption of a medication is through capsules or tablets with built-in sensors. These “digital” pills are innovative, as they are able to register information on what the patient actually ingested. These data don’t lie, and they can be crucial in fostering transparent discussions with a patient and in making more accurate and appropriate clinical decisions regarding therapy needs. The FDA approved the first digital medicine system in 2017. 

Importantly, providers must understand a patient’s specific barriers to medication adherence through targeted patient interview. Specialized training in motivational interviewing (MI) can help clinicians elicit this information in a caring and collaborative way. MI is a theory-based communication tool with strong evidence for a positive impact on patient outcomes. It is defined as “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” 

MI comprises core communication principles as well as skills that allow facilitation.

 A major component focuses on decisional balance and internal motivation. Many patients need to weigh the pros and cons before behavioral change can be possible. Often, if the change is not occurring or if medication adherence is lacking or not improving, the cons for making the change are more significant than the pros. This is where decisional balance comes in, as the patient will not make the change until the pros outweigh the cons. Pharmacists are key members of the health care team and possess the necessary knowledge to assist patients in swaying the decisional balance toward the pros and help patients make the argument for change and improved adherence. The table provides examples of decisional balance as it pertains to medication adherence.

Reassure patients that they can share their true adherence behaviors without judgment in a shame-free environment. Instead of asking “Why aren’t you taking your medications,” rephrase the question as, “Many people have trouble taking their medications on a regular basis. Do you find that this is the case for any of your medications?” Generating the conversation in a blame-free environment will provide the opportunity for MI, during which pharmacists can help patients decide to change by drawing on the internal motivation they already possess. The application of this technique requires little time and can be largely effective. Understanding and training in MI can help pharmacists facilitate patient-driven behavioral change and improved medication adherence. How pharmacists ask the question matters. Frame the majority of questions in an open-ended manner, and encourage patients to come up with their own solutions. Below are examples to help get the medication adherence conversation started. 

How often do you have difficulty remembering to take all your medicines? How often do you have to stop your medications for any reason? Sometimes we get busy and we do not take all the doses of our medicines. How many 

times in a given week do you miss taking your medicines?

Taking medication every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your regimen? What gets in the way of taking your medication as prescribed?

Despite all the combined knowledge and sophistication in this area, the industry has not made significant strides to improve the overall burden of medication nonadherence over time. Frankly, the United States does not have a health care delivery structure in place to address around this complex conundrum and produce widespread improvements. We have moved the needle to use better language, such as adherence instead of compliance. We have moved the needle to design and develop packaging strategies and technical aids. We have moved the needle to develop medications that patients do not need to take as often in a given day or week and have even advanced synchronization of refills. However, we are still struggling to get at the core of the instrumental importance of the individual’s care perceptions and motivations. We do not, as a whole, take the necessary time to even ask. Instead, our patients hear across drive-throughs, pharmacy counters, and phone lines the all-too-common query “Do you have any questions about your medications?” 

We also often assume patients just take their medications as prescribed and recognize the importance of doing so. To physically take a medication is incredibly personal and thus needs an equally supported personalized plan to optimize the value of an intended medication. Such a plan is likely not going to be static and will take a proactive and engaging partnership with caregivers, especially with pharmacists. To get there, we all need to remember that the patient, not the product, comes first. With the right approach, patients will take ownership of the process and pharmacists will be able to offer guidance on strategies that can support patients’ medication and treatment goals.

Articles

Methods Include Bioingestible Sensors, Motivational Interviewing, Packaging and Reminder Technology, and Synchronization