Medication adherence: Access and burden (part 2, burden)

Many aspects can lessen a patient’s ability to adhere to a prescribed medication regime. In fact, after research, RxLive has classified six buckets, each covered in a separate blog or blogs. The access and burden bucket consists of barriers to treatment access and the burden that medication regimens can impose on patients. 

This is the second blog of a two-part series examining those potential barriers to medication adherence and the impact on optimal outcomes. This post covers burden; read the access blog here.

Burden: Influence on medication adherence

The perceived burden of a medication regimen varies between patients and their caregivers (if they have any), and can result in treatment fatigue or medication nonadherence. 

Studies show that the complexity of medication regimens decrease adherence. One study reported a 10% decrease in adherence with each additional daily dose of medication. 

A complicated regimen — with multiple meds, taken with or without food, at various times of the day, or for how long a time — can lead patients to throw up their hands in frustration. The burden can feel too great for the patient to achieve the optimal clinical results the clinical team is seeking.

The concept of the impatient patient may contribute to the level of burden a patient could associate with their therapy. The concept suggests that many people have an innate tendency to favor immediate rewards, though those with the “I want it NOW” mentality may well find their rewards can be smaller than the long-term ones. Linking this to drug therapy, the long-term reward in a chronic illness is to avoid disease complications. Yet, the immediate short-term relief from the burden the therapy poses on a patient’s daily life may prompt nonadherence. 

How pharmacists can identify burden as a barrier to medication adherence

Direct questioning during counseling sessions has often revealed burden barriers through the use of open-ended interviewing. Patient self-report medication questionnaires made available during prescription drop-off or via mail can help patients identify any burdens they’re experiencing. In addition, the patient medication profile can indicate a potential pill burden from multiple medications, or intrusiveness of the medication regimen with more-complicated regimens.

How pharmacists can improve medication adherence relating to burden

Motivational interviewing (MI) — MI is valuable within reoccurring pharmacist consultations to generate patient motivation, transforming the perception that the patient’s therapy is a burden into an awareness that their path to freedom from the more-imposing burden of their illness. By generating innate motivation towards a health goal and increasing the perceived value of the therapy, the burden will likely lessen or dissipate.

Intrusiveness of medication regimen — Pharmacists can generate and provide a local resource list of community-based peer-to-peer support groups, encourage the development of such low-cost programs within their clinical setting, or create an online support forum. Peer-to-peer groups educate and empower their members, reveal problem-solving tactics related to treatments or illnesses. They can also instill hope, and motivate and encourage patients through their shared circumstances. 

One study reported 100% adherence to the American Diabetes Association guidelines after participation in a peer-support program, Project Dulce. Success of such groups is well-documented for addiction recovery, mental health, weight loss, and those coping with chronic conditions. Patients can identify through their peers that the long-term benefit of therapy overweighs the perceived intrusiveness or “hassle” of their medication regimen. Through peer support, these groups can leverage their own relatable experiences, sharing affirming experiences that drive home the point that no participant is alone in dealing with adherence barriers and frustrations.

Pill burden — We work with the patient’s office team to reduce complexity through medication therapy management (MTM). This helps identify if daily doses can be reduced by switching to sustained-release options, which medications can be eliminated, adjusting the time of administration so that more medications can be taken at the same time, or if combination medications exist for any concomitant drug therapies. We work to time medication administration to coincide with a particular patient activity (such as a meal, or returning home from work), consolidate medication refills, and encourage use of a single pharmacy with auto-refill for chronic medications. 

Pharmacists or physicians should inform patients of the expected duration of their therapy so a clear and realistic expectation can be understood. Additionally, patients should be told about lifestyle or diet alterations that can be made that can possibly shorten the duration, or reduce the pill burden of certain medications for chronic illnesses that are impacted by controllable factors.

Specificity of the regimen These factors — for instance, medication storage restrictions, administration requirements such as to take with or without food, or the amount of time needed to manage the treatment — can create a burden on patients that can negatively impact their adherence. Pharmacists should identify if an alternative, more-flexible medication option exists and notify the prescriber for a recommended change due to an adherence issue. 

Strategies can also be suggested to the patient to prevent treatment fatigue such as creating a written medication schedule, using technical innovations for reminders or administration devices, or calling upon the assistance of their social support network, such as caregivers, family or peers.

Summary

Pharmacists must recognize that despite documented benefits of medication therapy, the burden of the treatment may be significant and contribute to nonadherence. Pharmacists are in a position to use their clinical knowledge and medication expertise in a live or telehealth setting using motivational interviewing and planning strategies. This will help reduce a patient’s perceived burdens relating to their therapies, increase medication adherence and, hopefully and ultimately, optimal outcomes.

Resources

Adherence to Medication. NEJM

Is There an Impatience Genotype Leading to Non-adherence to Long-term Therapies? DiabetologiaReducing Barriers to Medication Access and Adherence for ACA and Medicaid Participants: A Peer-to-Peer, Community-Based Approach. AJMC

Author avatar
Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.