When patients don’t take their prescription drugs

One of my favorite patients in residency was a lady in her seventies who had longstanding high blood pressure, high cholesterol, and diabetes.

Each time she visited the office, I would recommend that we start multiple medications to control these conditions, and every time she would politely decline. Her previous physicians had left frustrated notes in her chart littered with terms such as “non-compliant,” “against medical advice” and expressing wonderment why she even bothered to show up.

I wondered, too — for show up she did, never missing an appointment but always turning down every drug we offered.

This type of patient drives most doctors nuts. I took a more philosophical approach: at least I knew exactly where she stood. Other patients, I suspected, simply accepted proffered prescriptions without protest and then never went to a pharmacy to fill them. Later, as an attending physician, the first thing I’d tell students who wanted to reflexively increase the dose of an apparently ineffective drug was, “make sure that they’re actually taking the meds.”

The extent of the problem of “primary medication non-adherence” (not filling the initial prescription for a new drug) became much clearer with the publication of a study in the April 2010 issue of the Journal of General Internal Medicine that found that a whopping 28% of new prescriptions were never filled.

What were the most common types of drugs that patients never picked up? Those for high blood pressure, high cholesterol, and diabetes.

There are many potential explanations for why patients don’t take prescribed drugs, ranging from cost to convenience to the patient’s not being totally convinced that the drug is necessary to treat an asymptomatic condition. But many doctors aren’t really interested in talking to patients about it, asserted surgeon Pauline Chen in a recent New York Times column:

While anyone who has ever tried to complete a full course of antibiotics can understand how easy it is to skip, cut down or forget one’s medications altogether, bringing the topic up in the exam room feels more like a confession or inquisition than a rational discussion. Few of us want to talk about medication non-adherence, much less admit to it.

Fair enough. But there are plenty of good reasons to change this mindset. Prescriptions that aren’t filled can’t do any good, but they can easily do harm: for example, in the diabetic patient who is hospitalized for an infection and given his “regular” insulin dose, only to become comatose from low blood sugar because he never actually took that dose (which his puzzled physician kept increasing) in real life.

The patient I mentioned earlier eventually suffered a stroke, the unfortunate consequence of not taking medications for her conditions. Had I assumed that she had been taking her medications, however, my colleagues might have pursued a more aggressive — and totally unnecessary — workup to explain the cause of the stroke.

Instead, she returned to my care a changed woman, resolved to take the drugs that she’d previously avoided, and her blood pressure, cholesterol, and blood sugar rapidly returned to normal. An interesting finding in the non-adherence study was that patients were less likely to fill prescriptions of specialists than those of primary care physicians. It goes to show that a family doctors know that their job isn’t done once the prescription is written. If that’s all it took, we — and the specialists who often have more tenuous relationships with patients — might as well be pharmacists.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • http://glasshospital.com GlassHospital

    Good post. I have a lot of patients like that. Only after they get the vascular event that you’ve been warning them about do they get the gospel about wanting to follow your plan and take the pills.

    It’ll last a year if you’re lucky–then she’ll decide she doesn’t like the pills again. When you ask her what effects they cause that she finds untoward, I doubt her answer will fit into your medical model. You’ll know where she stands. Again.

    Here’s a post of mine on med reconciliation:

    http://glasshospital.com/2010/04/11/med-reconciliation/

    -Dr. John

  • http://drpullen.com Ed Pullen

    I find more often patients non-verbally tell us about their reluctance to take medications, or speak in code, i.e. “Is there any more natural way to help my blood pressure?” Many patients I think feel taking medications is a failure on their part to somehow control things otherwise. Nice post.

  • http://drgrumpyinthehouse.blogspot.com/ Dr. Grumpy

    It’s always tricky. Like you, I often wonder why they return to see me, when they don’t want anything from me.

  • http://distractible.org Rob

    Good post. I do think that we as doctors can only go so far. Primary care has an advantage because we can build their trust over time, but some people will always resist. Our job is to never give a prescription without telling why we give it, and making sure the patient actually understands our explanation. Once we have done that, any noncopliance is not on us. We just need to be continuing to have them build confidence in us.

  • http://bittersweetmedicine.com DrLemmon

    I always try for compromise. I let them know we can always stop the med or try another if there are problems.

    I also let them know I am starting at very low doses and will increase the medication slowly.

    I also like to give choices if possible and then let them pick.

    These things help a little with compliance.

  • dP

    Sure, go ahead and sh*t on the Pharmacist.

    You offer this entire piece discussing the merits of patient drug-education and compliance reinforcement only to then turn-around and offend those who help support you in doing such. Nice…

  • Kenneth Lin

    Dear dP – I don’t mean to disparage pharmacists. I think they put up with a great deal from patients and are excellent at what they do, which includes communicating with patients about benefits and side effects of drugs. (FYI my mother is a retired pharmacist.) But what I’m saying is that the doctor’s job isn’t done when the Rx is written, and we can’t turn over the whole job of drug adherence to pharmacists (and say it’s their fault when adherence is poor), or to the patient, for that matter. So I apologize if I offended you; that was certainly not my intention.

  • Linda

    I faithfully took medications prescribed for nearly a year. The side effects seemed to be worse than the condition they were treating. My PCP is very good, I understood the reasons the meds were prescribed and I trust my dr; however, after changing medications four times and still having blurry vision, dizziness, muscle aches, shortness of breath, etc, I have not gone back in for a re-check because I know that my doc will continue to urge me to take the drugs and I don’t wish to do so. I’m not non-compliant just to irk my physician. I know the long term consequences are serious but the short term consequences are pretty unpleasant. So I exercise every day and eat healthfully and hope it’s enough.

  • Kenneth Lin

    Thanks, Linda. That’s why I prefer the term “adherence” to “compliance,” which has a negative, paternalistic (doctor-always-knows-best) connotation. There are lots of reasons patients don’t take medications, and some make good sense. I wonder if your physician would be open to switching to a different drug for your condition?

  • http://www.facebook.com/boojeebeads Helen

    Good stuff. I am one of those who has a hard time taking my meds. Not because I don’t think I need them (BP, cholesterol, etc.) but because I just forget. I did rebel, at first, when the doc wanted me on cholesterol meds. Helen

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