6/1/2015 Practical Strategies for Improving Medication Adherence Descartes Li, M.D. Associate...

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04/18/23

Practical Strategies for Improving Medication

Adherence

Descartes Li, M.D.Associate Professor of Clinical PsychiatryUniversity of California, San FranciscoDescartesL@lppi.ucsf.edu

Medications don’t work in patients who don’t

take them.

By the end of the seminar, a participant will:

• Be able to list common reasons that individuals stop taking medications as prescribed.

• Apply, in clinical situations, the “medication menu” conceptual model of prescribing medication for chronic disorders.

• Understand the Stages of Change model.

• Apply, in clinical situations, motivational interviewing techniques.

Interventions to Improve Adherence

Almost all studied interventions that are effective for long-term care are complex:

• more convenient care

• information

• counseling

• reminders

• self-monitoring

• reinforcement

• Family therapy

Interventions to Improve Adherence

In a comprehensive review,

Only 49% of the interventions tested (19 of 39 in 33 studies) had statistically significant increases in medication adherence and

Only 17 reported statistically significant improvements in treatment outcomes.

Even the most effective interventions had only modest effects.

Conclusions: Current methods are mostly complex, labor-intensive, and not predictably effective.

Macdonald HP et al. JAMA. 2002;288:2868-2879

Case Vignette: A frustrating patient

AB is a 64 year old widowed woman with HTN and depression. She is on multiple anti-hypertensives. For the past year, whenever she presents to clinic, her blood pressure is quite high (ranging from 165-190/85-95).

Unclear if she actually takes her meds, but she states that she doesn’t always take all of them. She doesn’t like being on so many medications. She always comes to her appointments.

You are reluctant to increase doses or add medications lest she take all of them and drop her blood pressure too fast; yet, you are concerned about her stroke risk.

Practice interview

Find a partner

One person is the “Frustrating Patient”, the other is the “Doctor” (three is ok with one Observer)

Start with trigger question:

“What do you think about your blood pressure?”

What feelings developed in the Doctor?

Outline:

• Clinician Attitudes

• Epidemiology

• Reasons for Non-Adherence

• The “Medication Menu” Approach

• Stages of Change

• Motivational Interviewing

Clinician Attitudes• Better therapeutic alliance predicts better adherence

• Patients who are non-adherent are frequently frustrating and demoralizing to work with.

• Remember that non-adherence is the norm.

• What kinds of thoughts/feelings are generated by patient nonadherence?

1. Tuna A et al: Therapist characteristics and outcome of treatment of schizophrenia. Archives of Gen Psychiatry 1978; 35:81-85.

Clinician AttitudesFeelings/thoughts generated by patient nonadherence:• “The patient is being resistant/passive-aggressive.”

(Challenge to doctor’s authority)

• “The patient is manipulative and does not want to get better.” (blaming)

• “What could I do about it? The patient just did not cooperate with my treatment plan.” (Distancing)

• The Challenge: Assuming the appropriate amount of responsibility for treatment “noncompliance” or failure.

How does this affect our behavior?

Manifestations of clinician attitudes

• We feel hopeless about medications and prescribe medications we know the patient will decline.

• We minimize or ignore patient’s complaints of side effects.

• We lecture the patient on the importance of taking the medications “as prescribed.”

• We develop an overly confrontative style with the patient.

• We terminate treatment with the patient for non-compliance.

• Decreasing the patient’s sense that we are pressuring them paradoxically often leads to an increase in the likelihood that the patient will take the medication.

• “Resistance occurs when the patient does not do what the physician wants…and when the physician does not do what the patient wants.”

• “Patients are not noncompliant. Physicians are.”

How can we convey that we are “with” the patient, rather than

against them?

Outline:

• Epidemiology

How common is medication non-adherence?

• Poor medication adherence:

“America’s other drug problem”

– Vastly understudied relative to extensive literature on the effectiveness of pharmacotherapies

• Costs and outcomes– Adherent patients: 50% lower hospitalization risk, up

to 50% lower healthcare costs, lower suicide risk

– Bipolar• Typically associated with co-morbid conditions

• 50% or more take 4 or more chronic medications

Average Reported Rate Of Non-Adherence Is 43%

Source: Manhattan Research 2004 data

Reported rate of non-compliance

What’s At Stake? - Medication Non-Adherence Drives Up

Healthcare Costs

Failure to take medication as prescribed: Causes 10% of total hospital admissions Causes 33% of CHF hospital admissions Causes 75% of Schizophrenia admissions Causes 68% of NNRTI resistant/mutated HIV

virus Results in $100 billion/year in unnecessary

hospital costs Causes 22% of nursing home admissions Costs the U.S. economy $300 billion/year

(N Engl. J Med 8/4/05, National Pharmaceutical Council, Archives of Internal Medicine, NCPIE, American Public Health Association, AIDS 2006 20:223-232)

The Medication Adherence Solution

Outline:• Clinician Attitudes

• Epidemiology

Case Vignette

CD is a 64-year-old married man with severe asthma and COPD. He is chronically dyspneic but is very erratic with inhaled corticosteroids. He will take both inhaled corticosteroids and beta agonists, but only on a as needed basis. He has stopped smoking for two years, but has a 50+ pack-year hx. His EKG shows right-sided changes.

You are concerned about long term effects of undertreated asthma and COPD.

Practice interview

Start with trigger question:

“What do you think about your asthma?”

What were the reasons for non-adherence?

Reasons for Non-adherence

Self-regulation and Testing the IllnessThe Meaning of Medications and StigmaThe Addiction Myth and The Crutch MetaphorAmbivalence and DenialFear of Medication and Its Side Effects

Other risk factors: age, cost, low self-efficacy

Self Regulation and Testing

Self-regulation as opposed to adherence: About half of people who are non-adherent perceive

themselves as simply adjusting their own meds.

Why do people vary their medication regimes?Self-regulation*alcoholTesting (“Am I ill?”)

Conrad P. The Meaning of Medications: Another Look at Compliance. Soc Sci Med. 20(1), pp29-37, 1985.

The meaning of medications and stigma

“What does it say about me that I have to take this drug?”^• “I am sick!”• “Oh God, not this again.”• “I am defective.”

Can we replace these negative thoughts with more positive ones?

• No, only the patient can (but we can make suggestions)Can we instill hope in every patient?• No, but we can help them come to terms with their

illness.What kinds of thoughts go through your mind when you

take these meds? (behavioral incident technique)

Pills come with thoughts

• Understanding loss:– For some patients, medications symbolize hope (a

ticket to normality)

– For others, they symbolize despair and loss, a constant reminder that their lives will never be the same again

“I can’t put up with this anymore. I just don’t give a damn.”

• Stigma– “People with illness A are _______.”

– Taking medications acknowledges the illness and therefore, whatever stigma is associated with the illness

The Addiction Myth and the Crutch Metaphor

The patient asks: “Are antidepressants addicting?”• Should you wait until the patient asks?• Defining/differentiating from “withdrawal”.

Related to the Crutch Metaphor.• The patient states: “I don’t want to use a crutch.”• “Am I a self-reliant individual?”

How do you address these concerns?^

Dealing with Denial: Am I ill?

Question: When would you take insulin or an corticosteroid or an antipsychotic?

Answer: Only if you were pretty sure something very serious was wrong with you.

Similarly, patients are making the best decision they can, given their beliefs at the time. (remember: patients takes medications because of their beliefs, not yours.)

N.B.: Particular disorders in which patients often do not think anything is wrong with them.

Addressing “Do I have an illness?”^

• Illness is indirectly addressed by development of a goals (aka “Inquiry in to Lost Dreams”)– What does (disease) prevent you from doing that you

would really like to be able to do?

– Doing it for the family. (can develop affirmations: “this is for my daughter.”) or picture of family next to pill box.

• Elicit examples of family members/significant others with the disorder.

Dealing with Ambivalence

If the patient is ambivalent, don’t push too hard.Once a patient has started a medication and then stopped,

it is very difficult to get the patient to re-start same medication again. (Pt has to admit that they were wrong to stop in the first place.) – see “Stages of Change”

“I actually think it might be better not to make a decision today. Why don’t you think about it, talk it over with you spouse or friends, and next time we can talk about it again.”

“There’s no reason to rush a decision. Here is some more information on the medication. Read it and see what you think. Does that sound okay to you?”

Medication Sensitivity

Will the medication harm me?

“Doctor, I am very sensitive to medications.”

“Hey, you’re really not sensitive. Those are just common side effects.”

• What do you think the patient hears?

• Other potential responses?• “Given your sensitivity to medications, which are not

uncommon by the way, I’d like to suggest that we start with a really low dose, a baby dose, of the medication. What do you think?”

Technique: exploring medication sensitivity

1. “Do you think you are particularly sensitive to medications?”

2. Explore patient’s perspective: “What are some of the things that have happened that have shown you are particularly sensitive?”

3. Do not challenge patient’s perspective on medication sensitivity.

4. Ask patient permission to start at a “baby dose”. Remember to give rationale.

Side Effects

• “No patient has ever stopped a medication because of a side effect, unless the side effect killed him.” (Shea)

• Importance of perception

Outline:

• Epidemiology

Outline

1. Assess clinical situation

2. Negotiate treatment plan

Develop “menu” of options

Review options

Collaboratively agree on an option

3. Evaluate outcomes

4. Go back to 1.

Negotiate the treatment plan

• Use negotiating skills!

• You may have to compromise but make sure that outcome will be remembered or recorded and thereby influence future choices.

• Check to make sure that the patient understands and is in agreement with the plan.

• Epidemiology

Stages of Change

• Pre-Contemplation

• Contemplation

• Preparation

• Action

• Maintenance

Resistance

• Readiness to change is not a trait, but a fluctuating product of interpersonal interaction.

• Resistance and ‘denial’ are not traits, but are feedback regarding physician behaviour.

• Resistance is often a signal that the doctor is assuming greater readiness to change than is the case,

• And it is a cue that the counsellor needs to modify motivational strategies.

Pre-Contemplation Not considering change or is unwilling/unable to change

Contemplation Acknowledges concerns and is considering change but is ambivalent and uncertain

Preparation Committed to and planning to make a change in the near future but is still considering what to do

Action Actively taking steps to change but has not yet reached a stable state

Maintenance Has achieved initial goals and is now working to maintain changes

Case Vignette

EF is a 48-year-old married woman with FBS = 160 and her HbA1C = 9 and BMI = 30.9 (ht = 5’4”, wt = 180lbs).

A 6m trial of diet and exercise produced no change in weight or labs.

She says: “I know diabetes is a serious illness, but I really don’t want to take diabetes meds. My mother was on diabetes medications, then insulin, but she still died of kidney failure.”

Practice Interview

• What stage of change is she at?

• Trigger question:

What would you like to do now about your blood sugars now?

• Epidemiology

Motivational Interviewing

• Motivational interviewing is an interpersonal style, not merely a set of techniques

• Motivation to change is elicited from the patient, and not imposed from without.

• Primary clinician task is to facilitate expression of both sides of the ambivalence impasse.

• The counselling style is generally a quiet and eliciting one.

• The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

• The doctor respects the patient’s autonomy and freedom of choice and consequences regarding his or her own behaviour.

Motivational Interviewing

• Interviewing style elements:Ask open-ended

questionsConduct empathetic

assessmentsDiscover client’s

beliefsReflective listening

• Motivating strategies:Normalize doubtsAmplify doubtsDeploy discrepancySupport self-efficacyReview past treatment

experiences

Motivational Interviewing (continued)

What is Self-Efficacy?

• Belief in the possibility of change

• Patient is responsible for choosing and carrying out personal change

• There is hope in the range of alternative approaches available

Miller and Rollnick 1991

• Motivating strategies (continued):Provide relevant feedbackSummarize sources of non-adherenceNegotiate proximal goalsDiscover potential barriersDisplay optimismInvolve supportive significant others

Motivational Interviewing (continued)

Motivational InterviewingPrecontemplation

• Stay engaged with the patient: regular visits, maintain interest

• Ask permission: Would it be okay if we talked about your blood sugars?

• Keep the issue alive:– Elicit patient’s perceptions of the problem

– Examine discrepancies between patient’s and others’ perception of the problem

– Continue to educate patient (check for areas of knowledge deficits)

– Help significant other to intervene

Motivational InterviewingContemplation

• Normalize ambivalence (ie, indecisiveness)

• Discuss pro’s and con’s (hint: take the con’s side)

• Summarize arguments/obstacles.

• Ask about patient’s perceived self-efficacy– How likely do you think this will work?

Motivational InterviewingPreparation

• Offer menu of options for treatment and negotiate treatment plan

• Find out what worked the past, and what didn’t

• Anticipate and help lower barriers (eg, cost, family, convenience)

• Enlist local supports (family): have patient publicly announce plans

• Explore patient expectations

Motivational InterviewingAction

• Reinforce importance of patient’s commitment and perseverance.

• Acknowledge difficulties in early stages

• Identify with patient future obstacles

• Assess social supports (or problems)

Motivational InterviewingMaintenance

• Affirm patient’s adherence and self-efficacy

• Maintain supportive contact

• Develop plan for non-adherence

• Review long term goals and reasons

Case Vignette

EF is a 48-year-old married woman with FBS = 160 and her HbA1C = 9 and BMI = 30.9 (ht = 5’4”, wt = 180lbs).

A 6m trial of diet and exercise produced no change in weight or labs.

She says: “I know diabetes is a serious illness, but I really don’t want to take diabetes meds. My mother was on diabetes medications, then insulin, but she still died of kidney failure.”

Practice Interview

• Assume she is at the Contemplation stage.

• What Motivational Interviewing techniques would you like to try?

Feedback and Summary• Clinician Attitudes

• Epidemiology

References

Shea, SC. Improving Medication Adherence. Lippincott Williams &Wilkens. 2006.

McDonald et al. Interventions to Improve Medication Adherence. JAMA, December 11, 2002—Vol 288, No. 22.

Haynes RB et al. Interventions for enhancing medication adherence. The Cochrane database of systematic reviews 2008 issue 2.

“TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment” Call U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES at (800) 729-6686 for a free copy

6/1/2015 Practical Strategies for Improving Medication Adherence Descartes Li, M.D. Associate...

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