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Medicines - Can’t take, Won’t take - Unlocking the reasons

Blogger . 18/02/2011 14:49:50
By Dr Joseph Bush, Lecturer in Pharmacy Practice, School of Life & Health Sciences

You could be forgiven for thinking that adherence – or more specifically non-adherence – to prescribed medication regimes is a relatively minor problem for the NHS.  However, non-adherence is a huge problem in all healthcare systems.  According to the World Health Organisation (WHO), in developed countries, adherence to long-term therapies in the general population is around 50% and is even lower in developing countries.  In England, between one-third and a half of all medicines prescribed for long-term conditions are not taken as recommended.  Estimates for the cost of unused or unwanted medicines in the NHS vary from £100 million to £300 million annually.  The economic costs are not limited to wasted medicines.   Non-adherence has the potential to limit the benefit of prescribed medicines.  A lack of improvement or deterioration in health has a direct impact on the NHS, with increased demand on GP surgeries and hospitals, all at an additional cost.

What makes figures such as those quoted above seem so shocking is that it seems a quite stunningly simple process to take a medicine properly – medication is prescribed; the patient is informed how to take their medicines; the patient obtains their prescription at a pharmacy; the pharmacist informs the patient how to take their medicines; ultimately the patient takes their medicines as instructed; [hopefully] the patient’s health improves as a result of taking medicines as instructed.  It would appear counter-intuitive for an individual not to take a medicine as instructed – why would a patient not take a medicine as prescribed?  Surely a patient who didn’t adhere to a prescribed medication regime could be considered be stupid, reckless or both.  To use Ben Goldacre’s Bad Science maxim “I think you’ll find it’s a bit more complicated than that”.

First of all in the scenario described above there is an assumption that the patient is a passive recipient of medical ‘wisdom’ and that it would be remiss of them not to heed said advice.  This is however, a spectacular over-simplification of what is at times a complex process.  The factors that can affect adherence to medicine regimes are myriad and diverse.  They straddle psychology, sociology, physiology, economics, pharmacology and logistics (and I make no claims that this list is exhaustive).

Obvious examples of factors which make adherence problematic include an inability to obtain the medicine in the first instance (through supply chain problems or an inability to pay for the medication for example), an inability to swallow solid dosage forms (this can be a particular problem in patients whose condition(s) leads to swallowing difficulties), unpleasant side effects of a medication and simply forgetting to take a dose.  There are however much more subtle forces at play that can determine whether an individual takes their medicines as prescribed or not.  For example, there are suggestions that some diabetic patients of South Asian origin may reduce the prescribed dose of medication that they ingest as they believe that medicines supplied via the NHS are more efficacious than those available in their countries of origin.  What is logical to one may seem preposterous to another.

It is into this maelstrom that the Aston Medication Adherence Study (AMAS) Team must throw itself (sounds overly dramatic – it’s not like we’re going to be climbing the north face of the Eiger or anything!).  First up is an assessment of levels of non-adherence amongst our study population.  This data will be analysed alongside relevant clinical markers (such as blood glucose or cholesterol levels) and patient self-reports in an attempt to devise a systematic approach to identifying non-adherence in vulnerable groups at the earliest possible opportunity.  While this itself is important, we also need to examine why our population do not always take their medicines.  This presents a tremendous opportunity to explore these factors amongst an atypical UK cohort – a hugely diverse population drawn from areas of significant socioeconomic deprivation.  It is only by understanding why people do not adhere that we can make constructive efforts to tackle medication non-adherence.  Improving levels of adherence will not only benefit patients but also wider society via decreased expenditure on costs related to non-adherence – highly pertinent amid the Government’s drive to deliver £20 billion of NHS ‘efficiency savings’ by 2014.

For more information check-out the Aston Medication Adherence Study (AMAS).

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