Drug non-compliance is an epidemic in the United States for a variety of reasons and it does not seem to be changing any time soon as Americans face uncertainties during the COVID pandemic and the cost of prescription drugs increase.
Current statistics show that one in five prescriptions are never filled and 50% of prescriptions that are filled are not taken correctly with regards to timing, dosage, duration and frequency. These numbers are alarmingly high considering nearly 3.8 billion prescriptions are written annually.
Not to mention, approximately half of the medication non-compliance population are those diagnosed with chronic conditions such as diabetes or hypertension.
The Cost of Drug Non-Compliance
The price of drug non-compliance is health related as drug non-compliance leads to a myriad of serious issues. A study estimated that nearly 40% of hospital readmissions were due to medication nonadherence. Another notable outcome is increased morbidity and mortality,it is estimated that drug non-compliance is likely the culprit of over 100,000 preventable deaths yearly.
Not only are there health costs associated with drug non-compliance but there is also a large financial cost as well – an estimated $100-300 billion worth of preventable, direct health care costs.
Reasons Behind Drug Non-compliance
There is often not one answer for why patients do not adhere to their medication regimen and the reasons can be one or many due to patient related factors, physician related factors or health care related factors.
Medication nonadherence can be linked to unintentional behaviors such as forgetfulness or due to cognitive health reasons impairing the individual from remembering to take the medication. Other reasons may be more intentional as Dr. Elliana Rose pointed out that a patient “may feel anxious to take a new medication which may be due in part to the social stigma around the medication or the condition they have.”
Along with the aforementioned reasons, other factors play a role such as an individual’s proximity to a pharmacy or other social determinants such as “low health literacy, lower socioeconomic status, language barriers or poor understanding of disease state, trust issues towards the clinician” Dr. Ani Rostomyan, PharmD stated.
Due to the multitude of reasons for medication non-compliance, not all are covered below, instead here is depth look at four of the key factors that play a role in poor medication adherence by individuals residing in the United States.
Increasing Cost of Prescription Drugs
One reason for patient related drug non-compliance comes from the cost of prescription drugs. This is not surprising as the cost of prescription drugs has been on the rise and is increasing at a rate faster than inflation. According to AARP “RX Price Watch”, the prices for 260 commonly prescribed medications had increased 2.9% while inflation had increased 1.3% from 2006 to 2020.
One notable drug increase mentioned in the AARP was the 42% price increase for the diabetes medication, Victoza, from $7,936 to $11,300. While this price increase is on a retail level, these higher prices find their way into health insurance premiums and increase taxpayer costs for programs such as Medicaid and Medicare.
In 2020, the total prescription drug expenditure topped out at $365 billion. This follows a hike in prices that was observed in a 2019 survey that found around a third of Americans noticed an increase in out-of-pockets costs for their medication. The same survey found that those who experienced increases in the cost of prescription drugs were more likely to not fill prescriptions, avoid medical care, as well as cut out other necessities in order to afford their medications.
Another example was shown by a study focused on patients with atherosclerotic cardiovascular disease (ASCVD) where medication nonadherence was found to be particularly high. It was found that about one in eight of the patients either skipped doses, took less medication, or delayed refilling a prescription all in order to save money all due to the cost of prescription drugs.
A price associated healthcare related factor that plays into medication nonadherence is providers inability to provide cost efficient alternatives to the prescribed medications in a timely manner. As Benjamin Gibson, PharmD weighed in stating, “patients and doctors do not know about their copayments. Insurance companies need patients to try the cheapest medications first and then fail them before they spend much more on a very expensive medication.”
Even if individuals have insurance to help with drug price coverage, plans are changing to include higher deductibles to cover the rising cost of prescription drugs. It is now estimated that 44% of insurance plans require an individual to meet a deductible before covering costs, meaning the individual must pay full costs for their medication until the deductible is met.
Communication barriers often lead to drug non-compliance amongst patients. This miscommunication or lack of communication can be on behalf of providers as well as the healthcare system as a whole.
An example of provider related factors causing non-compliance is limited coordination and communication between care providers especially for individuals seeking a diverse range of care from various care providers. While an issue on behalf of the healthcare system is the limited amount of resources of culturally appropriate information for patient education. These issues can be particularly difficult for patients with complex regimens as information and labels are not always as clear as necessary for those that have lower health literacy.
These factors play into drug non-compliance especially when patients may not fully understand the long term importance of continuing to take their medication and to only stop medication when advised by their doctor. As Joanna Lewis, PharmD described, “patients stop taking medication for a few reasons but two that are often seen are due to side effects or feeling improvements and thinking they no longer need to take their medication. This happens commonly with blood pressure medicine. High blood pressure is called “the silent killer” because patients often feel okay in earlier stages of the disease. Once they start taking the medicine, their blood pressure improves but the patient starts to feel bad because of side effects. They stop the medicine because they think they felt better before they started taking the medicine. We also see this with antidepressants or other maintenance medication – a patient will start feeling better as their depression symptoms go away, so they stop abruptly.
Drug Side Effects
Side effects are also a common driver behind patients’ medication non-compliance. There are many reasons why patients may come to fear the side effects of their medication whether that is due to someone they know experiencing bad side effects or feeling poorly themselves. This is particularly difficult when patients felt healthier before starting medication than they do after beginning their regimen.
One study showed that 86% of patients using antipsychotics to treat schizophrenia experienced at least one side effect and among this group only 43% reported complete adherence. While another study found that 3 out of 10 people suffering from chronic illnesses experienced adverse side effects and 21% of these respondents attributed their nonadherence to the unpleasant side effects.
As Dr. Lewis explains: “we find it important to educate patients that some side effects will go away within a few weeks, some are there to stay, and there are some that would be cause for discontinuation. Otherwise, they may decide to stop taking their prescriptions because they feel ill.”
As with any new habit, remembering to take medication can be difficult. Both Dr. Lewis and Dr. Rose weighed in that forgetfulness seems to be a large factor into why patients become noncompliant because not only do patients need to remember to take their medication, but also need to remember to refill and pick up the prescriptions.
A study done by Express Scripts in 2011 identified around 39% of nonadherence in patients was due to forgetfulness. This seemed to be particularly prevalent amongst the younger population often due to changing schedules and unset routines.
Dr. Rose believes the best way to improve compliance is for pharmacists to “encourage patients to use reminders, download relevant apps and use pill organizers. Also it’s important to facilitate relationships between healthcare providers and patients so that they can feel safe to communicate.”