The Hidden Work Behind Medication Adherence

Pharmacy staff talk about, counsel about, and worry about nonadherence on a regular basis. A 2021 meta-analysis (N = 8949) found that patients who have multiple chronic conditions are nonadherent between 44% and 77% of the time.¹ Researchers report that it is a multifaceted issue and may be intentional or unintentional. Factors that contribute to nonadherence include the following^2,3:

• The patient’s diagnosis and understanding of its implications
• The prescribed medication and its adverse effects
• The patient’s individual circumstances, including cognitive ability, socioeconomics, and culture
• Systemic health system barriers
• Geographic location and associated logistics

Table 1 lists many factors that contribute to nonadherence. It is often difficult to tease out all these factors in the limited time that the pharmacy team has with their patients. Many adherence strategies are well known to the pharmacy team, but unless the patient is amenable and reliable, strategies to mitigate them will not be effective.

Scope of Treatment Burden

One of the most significant contributors to nonadherence is treatment burden, yet it is an area where pharmacy teams can make a measurable difference. Medication adherence involves more than swallowing pills. Challenges may arise from forgetting doses, questioning treatment, and the burden of medication management. For some patients, organizing medications, obtaining refills, and preparing pill organizers may become barriers to adherence even when the motivation to take the medication remains intact. In other words, every diagnosis comes with a workload.

Planning Medication Schedules

Once patients have more than 1 or 2 medications, planning their medication schedules can be challenging. If they leave the pharmacy with a bag full of pill bottles, they may arrive home and wonder what to do if they have, for example, a medication that says, “Take 1 tablet every morning on an empty stomach,” and another that says, “Take 1 tablet every morning with food.” Although numerous electronic tools provide medication reminders and adherence monitoring, relatively few systems exist to help patients construct simplified medication schedules. As polypharmacy becomes increasingly common, tools that reduce the cognitive burden of medication planning may represent an important but underdeveloped area of adherence support.

Until then, pharmacy staff need to fill this gap. Suppose a patient takes levothyroxine (which must be taken on an empty stomach), immediate-release metformin twice daily, lisinopril daily, atorvastatin daily, and a calcium supplement. Pharmacy staff can take a few minutes to help the patient develop a schedule like the one in Table 2. The emphasis needs to be on taking the medication consistently at a time that fits their routine and minimizing adverse effects. In this example, where the patient has 4 “medication events” daily, eliminating even one of them might help.

Organizing Medications

Data from an international survey show that patients in 34 countries spent around 35 minutes every week organizing their medication.³ In addition to organizing medication, patients need to store medications correctly and safely. These in-home tasks often lead to out-of-home tasks, such as scheduling appointments to see a prescriber for refills and picking up prescriptions.³ For patients managing multiple chronic conditions, spending 35 minutes each week organizing medications may become yet another task competing for limited time and energy.

Pharmacies can help with this task in various ways. One is to dispense medication in multimedication packaging (MMP), which is oral solid medications prepackaged into patient-specific doses organized by administration time, if the technology is available. Manual preparation of MMP becomes difficult to sustain at a large scale, so automation, verification imaging, and software integration are increasingly viewed as necessities rather than extras.⁴

One disadvantage of MMP can be that patients who use it are less likely to know the indications for each medication than those who receive their medications in traditional packaging.⁴ This suggests that pharmacists may need to spend a little more time with patients who receive MMPs. Pharmacy staff should also remind patients that MMPs are not child resistant and must be stored carefully and out of sight and reach of children.⁵

Maintaining Medication Supplies

Refilling medication is also a burden for patients.³ Increasingly, pharmacies are recommending autofill, in which the pharmacist automatically calls the prescriber when refills run out and requests a new prescription, and auto-refill systems, in which the pharmacy automatically refills prescriptions when the patient should have used 75% of the medication.⁶ They can be helpful for patients who simply forget to refill prescriptions, as they remove the decision of whether to fill or refill a prescription. Although these systems improve convenience, they may occasionally generate refills that patients do not yet need. When paired with an automated phone call reminding the patient that a prescription is ready, the patient may pick it up.⁶ A simple solution would be for a pharmacy employee to check with the patient before filling the prescription; yet most pharmacy employees do not have enough time to do this.

Conclusion

Despite all that is known about nonadherence, it is critical to identify areas where patients need a little more help and some targeted counseling. Small interventions that simplify medication management can make a meaningful difference in a patient's ability to follow long-term therapy.

About the Author

Jeannette Y. Wick, RPh, MBA, FASCP, is the director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

REFERENCES

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2. Patel S, Huang M, Miliara S. Understanding treatment adherence in chronic diseases: challenges, consequences, and strategies for improvement. J Clin Med. 2025;14(17):6034. doi:10.3390/jcm14176034

3. Tran VT, Barnes C, Montori VM, Falissard B, Ravaud P. Taxonomy of the burden of treatment: a multi-country web-based qualitative study of patients with chronic conditions. BMC Med. 2015;13:115. doi:10.1186/s12916-015-0356-x

4. Martin-Oliveros A, Zamora JP, Monaco A, et al. Multidose drug dispensing in community healthcare settings for patients with multimorbidity and polypharmacy. Inquiry. 2024;61:469580241274268. doi:10.1177/00469580241274268

5. Gable CJ, Spencer SP, Middelberg LK, Scherzer DJ, Suer M, Casavant MJ. Pediatric exploratory ingestions involving novel pill pack packaging. Am J Emerg Med. 2022;282.e1-282.e3. doi:10.1016/j.ajem.2021.09.012

6. Evaluation of the Scale, Causes and Costs of Waste Medicines. York Health Economics Consortium; 2010. Accessed July 9, 2026. https://discovery.ucl.ac.uk/id/eprint/1350234/1/Evaluation_of_NHS_Medicines_Waste__web_publication_version.pdf