Go Ahead, Jump! Save

You write the prescription, hand it to the patient and explain why it’s needed, how to take it and what the most common or most dangerous side effects might be.

Comprehensive, reasonable, and professional. Certainly the patient should fill the prescription and start the drug. But way more frequently than you think, the prescription is never filled, or is not taken as prescribed. The World Health Organization estimates that only 50% of patients with chronic disease will comply with a prescribed regimen.

If you were in the patient's shoes, being handed a new prescription is very much like standing at the edge of Niagara Falls with a guide (physician) telling you, “go ahead, jump!”

The guide (physician) must think this is a safe and smart thing to do but, your intuition is screaming, “run Forest, run!” Run to the nearest Whole Foods where supplements, vitamins and OTC kale all seem to be safer options.

We all want to be safe and the smart path is the one that avoids risk.

We are all risk adverse. No one really wants to be wild and crazy. My version of wild and crazy is trying a Kombucha health shake.

Then there’s my crazy 30 yr. old cousin Frankie. He rides one of those smallish BMX bikes on handrails and does circus bike stunts on the highway while carrying his newborn son. Frankie’s all about risk, that’s why he has creepy open-eye tattoos on his eyelids and has a first name relationship with the local constable.

Unfortunately, one of life’s harder lessons, slowly if ever learned, is that when you go from being a person to becoming a patient, risk is part of the package.

No one wants to take medicine, 4 yr. olds cry and spit, 30 yr. olds invincibly don’t fill prescriptions; 60 yr. olds hide or waste pills and 85 yrs. cry and spit. If given the choice we would rather avert the disease, drug, risk and doctor.

Wouldn’t it be great if we knew if our patients filled and took their meds? I can’t understand why it’s ok for Pharma and IMS to know exactly how many prescriptions I’m writing for dapsone, but I have no data on patient prescription behavior? Managed care is only concerned with how many muscle relaxants I prescribe or if I’ve jumped through enough hoops (tests for TB, hepatitis, etc.) to warrant a new biologic prescription on their plan. Wellness never addresses compliance, but seems to be quite good at saving money and limiting access.

So what can you do to improve compliance and adherence?

1. Educate the patient. They’re not prepared for the diagnosis or the drug. And most believe that that all things medical will pass - the flu, the broken fibula, even his blood pressure problem was fixed by pills. You have to combat this with guidance, goals and managing expectations.
2. Simplify the regimen. Avoid piling on medications. QD is always better than TID.
3. Give written instructions. Medication lists, hand written instructions, notes on the back of a business card, etc.
4. Attempt to know: if they are compliant or not. Ask if they are? Do the math on pills and refills. Ask them to bring in bottles to see how and when they refill. Check drug levels (MTX, HCQ, etc.). The challenge is that there is no profile or demographic that predicts poor adherence. Studies have shown that race, sex, education, intelligence, marital status, occupation, income, ethnic or cultural backgrounds do not predict adherence to the plan.
5. Help them avoid bad behaviors.  Send reminders; call with followup encouragement; enlist the help of a family member; or utilize a clinical pharmacologist to review medications and find ways to avoid polypharmacy.

Many believe that the patient is the source of the problem with compliance and adherence.  

Instead it's the physicians who are at fault for not teaching the patient, wisely and authoratatively, to be a better patient.