Gettysburg Medical Center
 The Clinical View
 by P.E. Hoffsten, MD
 18 January 2006

MEDICATION PROBLEMS – I

            From the time of the Greeks and before, historical records mention various preparations and potions prepared from leaves or roots or cobwebs or owl feathers or something that were offered for cures for various ailments.  In pictures available, these are depicted as tasting horrible.  Some of these preparations persist today such as colchicine that came from the “autumn crocus” plant and treats gout.  Another is quinine to treat malaria.  It came from the South American cinchona tree.  But most of these preparations have long since been abandoned and replaced by our modern pharmaceutical industry.  The side effect profile for the age old natural colchicine and quinine scare most people into not using them.  And those drugs have never been tested by the modern methods we use to bring a drug to the market.

            Today, a new drug coming on the market costs the pharmaceutical company at least $100 million dollars by the time all the research and testing of the drug is complete.  We complain bitterly about the high cost of our medications but the truth is that the safety of our patients comes at a high cost for the development of these drugs.  Even once a drug is well developed, disasters can happen and products such as Vioxx are lost from the market.  The liabilities that come from problems such as Vioxx can far exceed the original cost of the development of the drug.

            But as I look back over the many years of new drugs coming on the market, I am struck not by the disasters but instead by the many successes the pharmaceutical industry has had.  In spite of obstacles and questions, the anti-cholesterol medications of the statin drug family (Mevacor, Zocor, Pravachol, Crestor, Lescol) have been a huge success in preventing heart attacks and strokes.  Other medications are in development and in 50 years these drugs will probably seem obsolete; but at least for now, they are highly beneficial.

            So what is the problem?  Do we need a better pill?  The answer to that question is no.  The pills that we have work remarkably well with a vanishingly low side effect profile.  The problem is that people won’t use them.  Repeated surveys have been done to measure how well a person will follow a prescription protocol.  The person goes to the doctor (except of course, for South Dakota men) and receives a prescription for a statin drug.  The medication must be used on a daily basis.  As long as the medication is used the serum cholesterol stays down and heart attacks and strokes are prevented.  But when surveys are done to see who is still taking their medications 3 months, 6 months and a year later, it turns out that only about 1/3 of the people who are ever prescribed the drug are still taking it!

            It turns out that of all of the people prescribed a drug, 10% never fill the prescription!  Another 12% fill the prescription but then never take the medication!!  So on the average, 1 in 5 people who are given a prescription never take the first pill.  By three months after the prescription is started, only 60% of the people prescribed medication are still using it.  By one year, only 40% of the people who are prescribed a pill are still using it.  Somehow, adherence to the drug prescription bottoms out at 30% after 5 years and then seems to remain stable after that.  In other words, 2 out of 3 people who are given a long term medication don’t follow the prescription.

            To correlate with this, the national government has done surveys to determine how effectively individuals with abnormal cholesterol are treated.  It turns out that about 1/3 of the people who have an abnormal cholesterol are effectively treated.  Note this correlates almost perfectly with the number of people who are still taking their medication.

            What a disappointment!  Here the healthcare providers working with the pharmaceutical industry come up with a very effective medication with substantial benefits and minimal side effects, but 2 out of 3 people won’t use it.

            Somehow the myth persists that oatmeal or exercise (which few people stick with) or diets (which nobody sticks with) or the hope that just wishing is enough to bring the cholesterol down by itself.  For our general population, all of the above are myths.  They just don’t work as a general public health measure.

            When an individual is asked about why they did not take a medication, reasons offered are too varied to even tabulate.  But large surveys have been done to determine the predictors of non adherence to a drug program.  Characteristics of the person that is non adherent include their being younger, male, and single.  As a group, the non adherent patients don’t have symptoms. They simply have an abnormal number on a lab slip that as far as they are concerned is not bothering them.  They don’t need a medication the way they think about it.  As a group, the non adherent population has had no vascular event such as a warning heart attack or a transient ischemic attack with a threatened stroke.  As a group, they have no single health care provider.  They tend to go to multiple different healthcare professionals.  As a group, they tend to have more depression symptoms than the general population.  They feel hopeless so taking a medication is of no use the way they see it.  Lastly, individuals who are prescribed multiple medications tend to let several of them lapse.

            In regard to the characteristics of a medication, problems that lead to non adherence include the cost which is the most prominent problem.  Hopefully, Medicare Part D will help some of this.  Other characteristics of the medication that make it difficult to use is the need to remember two or more doses per day.  Multiple adjustments in dose or type medication lead to frustration and the person tends to abandon the medication.  And lastly, perceived side effects regarding the long term use of a medication seem to inhibit the person using it.

            I haven’t a clue how to fix all of those problems to make it easier for a person to use a beneficial medication.  The next column will address the question of how to help a person adhere to a drug program to receive the benefits without the hassle.  The healthcare providers at your local clinics are well aware of drug adherence problems and can help an individual start and maintain a beneficial medication program.