Drug Compliance

For people with chronic diseases, medications are often as much a part of the daily routine as brushing teeth. Some may only require a single, daily pill. Other regimens, such as some of those used to manage congestive heart failure or HIV disease, require complicated pill schedules that could confound even the most diligent and organized individuals.

Dr. Susan Ball, Associate Professor at the Weill Cornell College of Medicine, is well versed in problems related to compliance. With a full roster of HIV patients, she struggles daily with issues of medication adherence. She tries to craft drug regimens with her patients that will better suit their lifestyles and ensure their success. Still, Ball says, "The burden really is on the patient." Below, she speaks to important compliance issues that are important for anyone who must stick to a drug plan in order to maintain good health.

First, are there certain people that are more prone to poor drug compliance?
Historically, there have been a lot of adherence studies done with tuberculosis patients that are relevant to look at in considering that question. It has particular relevance for the HIV-infected population who are taking antiretrovirals. Treatment to cure tuberculosis requires taking medication for about six to nine months and in some cases longer. It usually requires taking medication on a daily basis, or in some programs, medications several times a week. The studies that were done were looking at who failed treatment, and why.

They had populations of people with TB from all kinds of socioeconomic backgrounds, races, and both genders. The results were interesting. There were no distinctive personality traits that could predict who would succeed and who would fail with a drug regimen. It wasn't necessarily the IV drug user that couldn't or the person on Park Avenue that could maintain a good regimen. I find in my practice that some patients who I imagine are not organized enough to brush their teeth in the morning are absolutely diligent with their HIV medicines and have really good results for a sustained period of time. And some of the patients who are very organized, are working, have children, or have really very structured lives, can't. Adherence studies among HIV-infected individuals yield similar results. There is really no personality profile that you could point to as a predictor.

What are some of the reasons why people find it difficult to comply?
There are many barriers. One barrier is the number of times that pills must be taken each day. Patients who are taking medications that require three-times-a-day dosing, for example, may have difficulty remembering that middle dose. How many times a day is a very important factor.

Pill burden, or the number of pills, can also be daunting for some patients. They just don't want to take so many pills. I can't tell you how many times I've heard that.

Sometimes just the reminder of being sick is a burden that can prevent good compliance. Even patients who must take only one pill a day will sometimes say, "It reminds me of my illness every time," and that becomes a barrier for them.

Then there are the lifestyle-related issues such as, "I work, and when I get home, I'm really tired. I don't remember," or "I remember my pills every night before I go to bed, but in the morning I have so many things to do I can't remember," or "I get my kids out of bed and I give them their medicine, but I forget mine."

Then of course there is the whole issue of side effects. If a patient experiences or thinks he or she experiences a side effect with a medication, it makes adherence that much more of an issue.

Are there any tips that you have found to be helpful to people to improve compliance?
Yes. We have a dedicated nursing staff who work very closely with patients. The nurses will organize a week's worth of medicine for the patient in a box. If we're having compliance problems, we'll have the patient come every week and we'll lay out every single pill for them. They bring their pill box in every week, and ideally that pill box is empty every week because they've taken all their medicine. If it's not, we discuss the reasons, and this kind of direct monitoring, and direct discussion, is very helpful.

If the patient is put on some new medicine, we call them up. The nurses follow-up, give them encouragement, and find out if there are any problems.

We also have pharmacies that will call the patient when they need their renewals and their refills and tell them they need to call their doctor if they don't have a refill. This is very helpful. Sometimes patients will say, "I ran out of medicine and I couldn't get to the pharmacy, so I missed three days." We try very hard to make sure that doesn't happen.

Are there any memory devices that you think are helpful?
Sometimes patients will have alarm clocks, or wrist alarms. A couple of my patients have used those. I'm not sure that they work well in the long-run, however.

Instead, we try and urge patients to link their medication to something that they do every day. If they get up and brush their teeth, they should have their pill bottles right there. If they take their medicine at work, they should have a visual or scheduled reminder to take the medications at the same time each day, so it becomes a mechanical thing. If they watch "I Love Lucy" every night at seven, make the medication part of that ritual. That seems to be the best way to get patients to be consistent.

Ultimately, it boils down to the patient making that leap to link two things or two activities. The patient has to make that commitment, so that they really get it done.

What is the role of the healthcare provider in making sure that patients are adhering to a regimen?
We're very clear, for the most part, to say that this is not like bringing in homework. It's for them. Good drug adherence will benefit the patients. We make sure that patients know we are always available to talk, 24/7. And we also try and see the patients on a regular basis. In the case of HIV patients, sometimes it is very helpful for patients to get direct, concrete results, and see if their numbers are improving or not. It brings the importance of good compliance into the front of their minds.