The “Other” Drug Problem

by on August 28, 2013

C. Everett Koop, who just passed away this past February, was U.S. Surgeon General under President Reagan, the only one, as Salon put it, to become a household name.drug_compliance


Koop had something worth saying about medication “adherence,” meaning the degree to which patients take medications as they’ve been instructed by their health care providers.


Said Dr. Koop:


Drugs don’t work in patients who don’t take them.”


And though he could not have been more right, and though not taking one’s medications can lead to devastating consequences, medical nonadherence persists in this country, to the extent that it is  called an “invisible epidemic” and America’s “other drug problem.”


In fact, in the U.S., 20-30% of prescriptions are never even filled—and then, after that, within one year, 50% of patients discontinue their medications, with an additional 35% discontinuing them the following year (National Council on Patient Education and Information).


These rather pathetic percentages cross diseases and are found among illnesses that I, for one, find frightening enough to play a role as ‘fear factors.’


Take a heart attack.  The experience is lousy enough I’d think people would do anything not to repeat it.


It seems I think wrong.


Jackevicius et al (2008) studied long-term adherence to prevention therapies for heart disease. And what should they find, but that that after a heart attack, nearly one-fourth of patients hadn’t even bothered to fill prescriptions by the 7th day after discharge. There’s a standard treatment protocol post-heart attack that includes aspirin, statins, and β-blockers. For those who at least went ahead and filled their scripts, researchers Ho et al (2009) followed them for a year and found that, while patients were pretty good about taking that aspirin 6-12 months after discharge (71%, according to self-report), their performance plummeted when it came to the rest of the regimen. Less than half (46%) were still on β-blockers or lipid-lowering meds (44%), and only 21% reported taking all 3 medications by the end of the year.


It’s well-known that the news is pretty bad for heart patients who don’t stick with their regimes.  For example, one major study showed that those who weren’t adherent to their statins in the year after hospitalization for a heart attack had a 12%-24% increase in mortality. Even worse, nonadherence to the standard regimen among chronic coronary artery disease patients was correlated with a 10%-40% increase in risk of hospitalizations related to heart problems—and a 50%-80% increase risk of death.


And what of stroke, another horrifying illness that attacks with deadly force, and you’d think a patient would want to strenuously avoid?


Hypertension is considered the single greatest risk factor for stroke (as well as one of the biggest risk factors for heart disease).  The need to lower blood pressure to prevent stroke is well-established. In fact, consistently taking antihypertensives decreases risk of stroke by 30% and heart attack by 15%, according to Brown and Bussell (2011). It seems such numbers would motivate people to keep popping their pills.


But they don’t. The same researchers found that 50%-80% of patients treated for hypertension are nonadherent to their regimen. The year before, Glader et al had found that a stroke’s ‘fear factor’ impact doesn’t last long at all.  Adherence to an antihypertensive regimen “declines rapidly during the first 2 years after a stroke.”


In one large study this year of 732,527 patients with high blood pressure, Herttua et al (2013) found that patients who were nonadherent had almost a four-fold larger risk of dying from stroke in the second year after having been prescribed the medication to control their blood pressure—and three-fold increase in the tenth year . Another study found 5.4 times increased risk of hospitalization, rehospitalization, or premature death for patients with high blood pressure who were noncompliant.


Speaking of deadly diseases, how can we ignore cancer?  With a name alone that inspires fear, the threat of death looms large in people’s minds once they receive the diagnosis.  This fear, you’d think, would yield adherence.  And once again—you’d be wrong. Kantar Health’s National Health and Wellness Survey (NHWS), the largest international self-reported patient database in the healthcare industry, came out with a shocking report  this May. It revealed that two-thirds of patients diagnosed with non-small cell lung cancer, melanoma, or leukemia had “engage[d] in at least one type of non-adherent behavior in their medicine use.” Two-thirds might just win them the non-adherence contest.


Granted that diabetes doesn’t have that single raging moment bringing untold suffering and possibly death in its wake, it’s still an illness that can cause much damage and suffering. Research has consistently shown that a significant percentage of those with type 2 diabetes have difficulty managing their medication regimens, which include oral hypoglycemic agents [OHAs] and insulin. Then Cramer, in 2004, ran a systematic literature search and revealed: 1) a surprisingly wide range of adherence with OHA (36%-93%); 2) that insulin adherence was lower than for OHA; and 3) self-reports of insulin use indicate that many patients frequently skip injections.


Ho et al (2006) studied 11,532 patients with diabetes and found “medication nonadherence remained significantly associated with increased risks for . . . hospitalization. . . and for. .  . mortality, while the American College of Preventive Medicine found a 2.5 times increased risk of hospitalization among those who didn’t comply with their regimen.


After the big scary illnesses, where death—or all sorts of incapacitations--threaten and loom, there are the less menacing chronic illnesses; those that don’t kill with a bang, but could, conceivably, destroy your health, bit by slow bit.   How, I wondered, do people do with those?


Lucky for me, Medscape wondered the same thing.


So they ran a longitudinal study in 2008 analyzing 706,032 health care claims for several conditions, analyzing adherence rates the first year after a diagnosis.


After what we’ve seen, some seemed okay. And that’s even without the ‘fear factor’ of hypertension or clogged arteries-—although, fear-wise, I wouldn’t need much convincing to follow the regimen to prevent another seizure, say.


To start at the top, hypothyroidism patients were 68.4% adherent, with hypercholesterolemia at

60.8%. Not bad--but you see we’re headed in the wrong direction. By the time we reach seizure disorder we’re down to 54.6%


Faught et al (2008) studied 33,658 patients who suffered from seizures—and found that nonadherence was correlated with “an over threefold increased risk of mortality compared to adherence,” while also associated with more emergency room visits, hospital admissions, and fractures.


But to return to Medscape. It asserted 51.2% of those with osteoporosis were adherent, although Solomon et al  in 2005 claimed that one year after beginning treatment, 45.2% of osteoporosis patients had stopped filling their prescriptions, and five years later, 52.1% had quit completely.


Bringing up the rear was gout, which Medscape politely referred to as “the outlier,” with 36.8% adherence. You can’t win ‘em all.


When it comes to psychotropic medications, the scene is no better.  Most estimates are that 50% of bipolar disorder patients are not medically adherent. Studies vary regarding unipolar depression, but aren’t particularly good. One study of 829 people found that within the first 30 days of starting an antidepressant, 42% had discontinued, and 72% stopped within the first 90 days. Another study of over 740,000 patients who had just started an SSRI, indicated that nearly half failed to take the medication for 60 days or more, and only 28% were still adherent at the 6-month mark.


The statistics for schizophrenics are even worse.  Researchers in 2004 analyzed Medicaid claims data from San Diego County—and found only 41% adherent to their antipsychotic medications.


Although nonadherence to chronic treatments gets the worst rap, compliance with short-term therapy is nothing to write home about either. Such adherence rapidly declines within the first 10 days. One study, of patients with lower respiratory tract infections, taking a short course of antibiotics, found 28.7% declining adherence over time, 25.3% nonadherence to correct dosing, and 3.3% “unacceptable adherence.”


To wrap up the stats, here’s a tidbit for irony’s sake: doctors and nurses have 84% adherence to long-term medication regimes—and only 77% adherence to short-term medications. Not much to write home about.


After all that you may be thinking, Isn’t a person entitled to stop his or her own medication, Koop or no Koop? This is, after all, a free country.

I would love tell you you’re right—you can stop your antihypertensives or insulin at will.


Except that nonadherence is a deadly serious problem. Serious for the patient, the patient’s loved ones, the treaters—and even the taxpayers.  A person becomes nonadherent at the peril of more sick days off work, more pain and suffering, more and more frequent hospitalizations and nursing home entries, and, most horrifying of all—an increased mortality risk.


In fact, Wertheimer and Santella sum up that approximately 125,000 people—with treatable diseases—die in the U.S. every year because of medical noncompliance.


That’s not to mention the extra hospital and nursing home beds occupied by those who skip their meds.  At least 10% of hospitalizations are made up of the medically nonadherent (costing around $47 billion each year) as are over 40% of nursing home admissions. In fact, between one-third and two-thirds of all medication-related hospitalizations in the U.S. occur due to poor medication adherence.


The cost isn’t just in human lives, unbearable as that may be, either—there’s a financial price to be paid, quite a heavy one.  It’s estimated that nonadherance costs the U.S. health care system between $100 and $300 billion every year. Additionally, it’s estimated to cost $2,000 per patient in doctor visits, according to the American College of Preventive Medicine.


Back to Dr. Koop for a moment. You don’t always need to memorize every word of your Surgeon General—but it is worth keeping in mind that drugs don’t work if you don’t take them.


It’s up to you.

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