Here’s why your patients disregard prescriptions

Take one-half tablet three times per day with meals, increasing by half each week until reaching a maximum of three tablets three times per day.

Did you get a new prescription from your doctor? If so, there is a 50 percent chance you will not adhere to label directions. Either the instructions are too complicated, the drugs are too expensive, you do not like the way the medicine makes you feel or a lack of physician follow up makes you question whether they are effective and still required.

Taking just the right amount of medication is rare among patients. Too much or too little is common. This frustrates diligent doctors trying to document effective­ness. It also wastes drugs and diminishes health. Through the eyes of patients, much of the prescription compliance problem falls on the shoulders of physicians. Most doctors reverse the blame. Likely, both are at fault to some degree.

I have respect for the years of selfless training that physicians under­take. Many are over­worked, yet they tirelessly care for patients streaming into waiting rooms day after day. Each comes with a unique problem and a different history. Yet inside of 10 minutes, a doctor usually offers a prescrip­tion based on past experi­ence and laws of averages — perhaps with the help of a computer. Following up about any adverse side effects is left to the patient.

Past situations shape compliance. I hope my experiences are unique but would love honest feed­back on how common they may be:

Who’s to blame?

Preliminary diagnosis: Raynaud’s Phenomenon (unconfirmed)

In my early 20s, a primary-care doctor over-prescribed medica­tions — usually by giving out samples. This kept costs down but circumvented pharmacy alerts. By addressing each symp­tom with three to five prescriptions, he had me on over 20 different meds at once. Let me take you through the rationale:

Explaining that cold hands are due to vaso­constric­tion, there is a need for vaso­dila­tors like atenolol, nifedi­pine, nitro­glycerin and high doses of vitamin E. However, this leads to hypo­tension, migraines, stomach irritation, and shock. Responding to this with triptans, sucralfate, famotidine, alprazolam, metoclo­pramide, and Mylanta leads to more drug interac­tions for which, yes, more drugs, emergency room visits, and hospital admis­sions are necessary.

After escalating to cardiologist, neurologist, gastro­enterolo­gist and oncologist referral consulta­tions, the latter broke the unspoken rule of not contra­dicting another doctor and recom­mended that I replace all the medica­tions with a multi­vitamin. In addition to learning not to take every­thing prescribed, I discovered two severe drug allergies and—thanks to emergency personnel — the value of Benadryl.

Preliminary diagnosis: Benign paroxysmal positional vertigo (incorrect)

When reporting to an otolaryngolo­gist a drug reaction to prescribed medication, he became visibly angry since I stopped taking them within the 2-week period between appoint­ments. Scolding me to respect him as the authority and refusing to prescribe an alternative led this office to having one less patient.

Despite voicing apprehension years later, the same drug (now available without prescription) was recommended by a physician’s assistant. The rare reaction of rapid heart­beat and tightness in the chest occurred again. (Kudos if you can correctly identify the popular drug from these clues.) After reliving the hour-long trauma in a supine position, I more empha­tically refuse this prescrip­tion that has been added to my elec­tronic medical record and the paper medical directive in my wallet.

Preliminary diagnosis: Confluent and reticulated papillomatosis (incorrect)

Following a punch biopsy with nonspecific results, a dermatolo­gist appeared to type something like “chest spots” into his exam-room diagnosis database and read off the first thing that popped up — a condition affecting most of the torso — not an area the size of a nickel. For this, an ineffective $500 ointment was prescribed. The correct cream costs less than 20 bucks.

Miscellaneous allergy-related diagnoses

Three doctors have asked me what drug do I want to try — as if the patient should know in advance. At least four specialists evidently prescribe the same medication to all their patients. One even added, ”More than half of them respond well.” Well good for them, but I am uncom­fort­able with suicide as a side effect.

A few black-box warning prescriptions and those with ingredi­ents to which I have had prior allergic reactions have been discontinued after depart­ment heads discovered the error. I was simply told the prescribers no longer work for the company and to stop taking the drugs immediately. While looking up side effects for one sample prescrip­tion handed to me by a well-meaning doctor, I discovered it had been recalled. Crisis averted before taking any.

Road to compliance

Mistakes can happen with anyone. But as an apparent lightning rod for botched prescrip­tions, adverse reactions must be my primary reason for non-compliance to varying degrees. I am also apprehen­sive about taking drugs indefinitely — especially when there is no apparent benefit. In my mind, ideal circums­tances for prescrip­tions with compliance looks something like this:

  • Evaluate thorough patient history
  • Accurately diagnosis condition
  • Provide easy-to-follow instructions
  • Determine if the patient can afford prescription
  • Identify a clear path to a favorable outcome
  • Short interval between follow up
  • Adjust according to patient reaction

My current physicians are asked to prescribe as low dose as possible to gauge reaction before increasing dosage. Lists of side effects and contra­indica­tions are studied prior to ingestion. This helps me to identify symptoms that should be alerted to my doctor immediately verses the next office visit.

Recognize that for some ailments, there is no medical cure. Prescribing medica­tions without likely recovery is frustrat­ing and expen­sive. The remedy may require address­ing a change in diet or physical fitness. For chronic pain, patient comfort is most desirable.

Online services and apps now allow prescrip­tion price com­pari­sons and coupons. This may not always be helpful when the doctor’s office requests, before you leave, the name of the pharmacy to send the prescrip­tion electronically.

Patients with several prescriptions might benefit from dividing them within daily pill containers. In addition to vitamins, I currently take one pre­scrip­tion at bedtime and another as needed. They do not cure all that ails me, but they are affordable, have predict­able side effects, and the steps for compli­ance are simple to follow.

Kevin R.R. Williams can be reached at and on Twitter @ClinicalPosters.

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