Thirty-two million Americans use three or more medicines daily, and 75% of adults taking medications are nonadherent in at least some way. 30% of prescriptions are never filled, and 50% of medications for chronic disease aren’t taken as prescribed. Those figures are from studies conducted before the pandemic — current rates may be even higher.1
A host of factors contribute to this problem, says Daniel Reichert, MD, medical director for the department of family medicine at Loma Linda University Health, California. He recommends talking to your patients about any barriers they face. You can address those concerns before they leave your clinic and develop “trusting relationships to influence [patients’] attitudes about taking the medications.”
Here’s a look at the most common barriers and how to address them.
Patients may not understand the need to start or continue taking a medication, particularly for an asymptomatic condition. Go over every medication and explain what it does, why it’s important, and why they should take the full course as prescribed, says Kelly Gibson, CRNP, an NP at Howard County General Hospital, Columbia, Maryland.
Explain why patients should finish antibiotics even after they feel better, for example. If you prescribe a medication for a non-traditional use, such as an antidepressant for pain management, make sure the patient understands that the medication has more than one use — that you’re not suggesting their illness is “all in their head.”
When replacing an old medication with a new one, make sure the patient understands the change. Gibson also notes that she makes sure the pharmacy has the correct information so patients can easily fill their prescriptions.
Medication adherence rates are typically lower among patients who belong to a racial minority or are socioeconomically disadvantaged.2
Across a wide range of illnesses, “beliefs regarding the necessity of a medication, and the level of concern about taking daily medications, differ among cultural groups,” Elizabeth L. McQuaid, PhD, ABPP,and Wendy Landier, PhD, CRNP,write in Cultural Issues in Medication Adherence: Disparities and Directions.2
“As an example, empirical surveys demonstrate that African American patients with HIV/AIDS have high levels of concern regarding antiretroviral treatment and HIV infection. Data from one large survey showed that, relative to other racial/ethnic groups, African Americans more frequently endorsed the belief that HIV is a manmade virus, and more often agreed with the statement that those who take antiretroviral medications are ‘human guinea pigs.’”2
Similarly, political affiliation is linked to mistrust of COVID-19 vaccinations and treatments. Ask patients if they have any concerns about medications and open a discussion about whether those concerns outweigh the potential benefits of medical care.
It’s important to consider the cost and availability of the medication you’re prescribing, says Alexis Chauvette, CPNP, PC, a nurse practitioner with Lehigh Valley Health Network in Allentown, Pennsylvania.
Approximately 39% of the 1,029 people who responded to a GoodRx survey reported that they reduce or skip medication doses because of prescription costs.3 Moreover, 37% said that paying for their regular prescription was difficult, 21% reported declaring bankruptcy or taking on debt because of prescription costs, and 21% reported struggling to pay for basic needs like housing and food because of their medication costs.
The Kaiser Family Foundation reports that the people most likely to face difficulties affording their medications include those who take at least four drugs monthly (35%), those who have monthly drug costs of $100 or more (58%), those who are in fair or poor health (49%), and those who have annual incomes below $40,000 (35%).4 Further,a 2021 report noted that Medicare and other insurance plans are increasingly shifting drugs into higher formulary tiers, making previously affordable medications too expensive for patients to refill.5
Before you write a prescription, ask the patient if they are concerned about paying for it and discuss any more-affordable options that may be available. Insured patients can call their insurance companies to check on copays and may be able to use drug-manufacturer coupons to lower their costs. Uninsured patients can visit websites like GoodRx to compare the price of a medication across a variety of retail stores.
Fear of Side Effects
Patients may see friends or family members experience side effects, or they may be influenced by inaccurate information from social media or other news sources.
Talk to patients about potential side effects and how to manage them from the beginning. For example, if you prescribe an antibiotic that tends to cause nausea, discuss also prescribing antinausea medication, Gibson notes.
“If patients know what to expect, they are more likely to either accept the side effects or agree to try to treat them.”
Conditions such as depression, anxiety, substance abuse, and cognitive or physical impairment can make it harder to take a medication as prescribed. Depressive symptoms have been linked to poor adherence to antiepileptic medications, oral medications for cancer, and asthma drugs.2Cognitive impairment is a risk factor for poor antihypertensive medication adherence, even in patients without dementia.7 A survey of patients with a variety of disabilities found that squeezing eyedropper bottles and opening childproof bottles are major barriers across groups. People with vision impairments reported difficulty organizing medications and self-administering the correct medication at the prescribed time.6
Inability to Pick Up Medications
In the aforementioned study, people with mobility impairments reported difficulty getting to the pharmacy to fill prescriptions.7 Travel may also be a barrier for people who don’t drive or have access to alternative forms of transportation. A growing number of pharmacies now offer prescription delivery so patients don’t have to travel.
Creating a Connection
The real challenge begins when a patient goes home. Before patients head home to pick up a new prescription, Gibson suggests allowing them time to ask questions and making sure they know they can always call you — even after they get home.
Partner with your patients, working with their preferences to choose the optimal medication to treat their condition, says Alexis Chauvette, CPNP, PC, a nurse practitioner with Lehigh Valley Health Network in Allentown, Pennsylvania. “There are a lot of questions we can ask … to ensure success in medication compliance,” she notes:
- Is the form of the medication tolerable? A liquid medication may be more convenient for some child patients, while a dissolvable may be a better option for others. Not all adults can swallow pills, especially if the pills are large, so talk to patients about whether a medication can be cut or crushed for easier swallowing and what alternative forms of the medication are available.
- Is the dosing frequency manageable? It’s easier for patients — adults and children alike — to take one or two pills each day than it is to take three or four.
- What kind of adherence aids would be helpful? Simple tools like pill organizers and phone alarms can help patients remember to take their medication. Patients have reported that 30-day pillboxes, packets of medications for each dose time, and longer prescriptions from physicians and pharmacies all help them better adhere to their medication regimens.6
- You can also suggest that patients tie medication time to a routine activity, like toothbrushing or another bedtime ritual.
- Mollison C. Concerns about medication adherence grow amid COVID-19 pandemic. Pharmacy Times.April 3, 2020. Accessed December 22, 2021. https://www.pharmacytimes.com/view/concerns-about-medication-adherence-grow-amid-covid-19-pandemic
McQuaid EL, Landier W. Cultural issues in medication adherence: disparities and directions. J Gen Intern Med. 2018;33(2):200-206. doi:10.1007/s11606-017-4199-3
Adams K. Rising costs force 39% of Americans to skip, ration meds, survey says. Beckers Hospital Review. March 22, 2021. Accessed December 22, 2021. https://www.beckershospitalreview.com/pharmacy/rising-costs-force-39-of-americans-to-skip-ration-meds-survey-says.html
Poll: nearly 1 in 4 Americans taking prescription drugs say it’s difficult to afford their medicines, including larger shares among those with health issues, with low incomes and nearing Medicare age. News release. Kaiser Family Foundation. March 1, 2019. Accessed December 22, 2021. https://www.kff.org/health-costs/press-release/poll-nearly-1-in-4-americans-taking-prescription-drugs-say-its-difficult-to-afford-medicines-including-larger-shares-with-low-incomes/
Avalere Health. Generic drugs in Medicare Part D: trends in tier structure and placement. May 22, 2018. Accessed December 22, 2021. https://accessiblemeds.org/sites/default/files/2018-05/Avalere_Generic_Tiering_White_Paper.pdf
Fain B, Farmer S. Medication adherence for older adults with disabilities: technical report TechSAge-TR-1701. Georgia Institute of Technology. 2017. Accessed December 22, 2021. https://smartech.gatech.edu/bitstream/handle/1853/58509/techsage-tr-1701.pdf
Cho MH, Shin DW, Chang S, et al. Association between cognitive impairment and poor antihypertensive medication adherence in elderly hypertensive patients without dementia. Sci Rep. 2018;8(11688). doi:10.1038/s41598-018-29974-7