THE STUMBLING BLOCK: DRUG COMPLIANCE FAILURE AND IT'S AFTERMATH

“The most expensive pill is the one which is not taken or taken inappropriately”

Health is a relationship between you and your body and drug compliance is the block of relationship which often more than not stumbles. ‘Compliance’ means the act of complying with a wish or a command. The extent to which a patient takes the medications as prescribed by the physician can be referred as ‘Drug Compliance’.

Recently few researchers prefer the term “Adherence to medications’ instead of ‘Compliance’, the reason being ‘Compliance’ implies the passive act of following the physician’s command while ‘Adherence” is active involving the physician and the patient. However, both are used interchangeably despite both being imperfect and uninformative.

Indeed, Patient adherence to medications is currently one of the biggest hurdles to better prognosis. Adherence rates, percentage of prescribed doses of the medication actually taken by the patient over a specified period, are typically higher among patients with acute conditions, as compared with those with chronic conditions.

The need to measure the compliance or adherence rate is on rise. There are direct and indirect measures to do so but none of them is gold standard. Direct observed therapies, measurement of concentrations of a drug or its metabolite in blood or urine or detection of a biological marker, are few examples.

It has been implicated to know the serum concentrations of antiepileptics such as valproic acid, phenytoin. But the use of direct method is of limited value due to it’s high cost. Indirect methods includes asking the patient how easy is it to take the medications, assessing clinical response, pill counts, questionnaires, electronic medical monitors, etc. The indirect methods may be susceptible to subjective errors. 

Failure to compliance has been a problem for very long. So, who is responsible for this catastrophic failure? Is it the patient or the physician or the nature of illness or the economic burden? Multiple factors act together which causes a missed pill or complete abstinence of the drug

Drugs won’t work until you take them. A physician can prescribe a drug but ultimately it’s the patient who has to take the drug. The chronic diseases have higher rates of adherence failure. Obviously, there is a psychological burden as well in chronic diseases which leads to failure of adherence.

The urgency to have the desired effect often leads to disbelief towards the medications in use. Further, Side effects of the drugs can be a problem. In a large systematic review of 76 trials in which electronic monitors were used, Claxton and colleagues found that adherence was inversely proportional to frequency of dose. The older patients tend to forget to take the drugs.

In a country like Nepal where health facilities and drugs are still unaffordable to a bulk of population, Patients don’t comply with their physicians. Further, the doctor to patient ratio is so low that physicians are unable to educate the patients adequately. And to add more to the problem, Patients commonly improve their medication taking behavior in the 5 days before and after an appointment with the health care provider, as compared with 30 days after, in a phenomenon known as “white-coat adherence”. It’s like brushing your teeth before visiting your dentist. Hence, White-coat adherence can lead to misinterpretations.

How can we minimize this problem? There needs to be an integrated approach grouped into four general categories: patient education, improved dosing schedules, increased physician-patient encounter and improved communication between physicians and patients. Not only the patient, but the patient’s family members should be involved in improving adherence. “cue-dose training” can be given to those who often miss their pills.

Cue-dose training consists of the use of personalized cues for remembering particular dose times and feedback about medication taking using Medication Event Monitoring System (MEMS) pill bottle caps. MEMS are capable of recording and stamping the time of opening bottles, dispensing drops or canister.

The physician should be non-judgmental while asking about the drug compliance and hence building a proper rapport with the patient. The physician should also take patient’s economic condition in consideration. The government should also step in to provide free medications for chronic diseases like Diabetes Mellitus, Cancer, etc to financially underprivileged.

Poor adherence to medication regimens is common, contributing to substantial worsening of disease, death, and increased health care costs. Multifactorial approach is required to improve the adherence. A good compliance can only lead to a brighter path in medicine. Hence, more health benefits worldwide would result from improving adherence to existing new treatments than developing any new medical treatments.

Nikesh Jaiswal

Medical Student BPKIHS Dharan