Medication Adherence Pharmacist-

1. Medication Adherence:
Pharmacist Interventions
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O G U N S I N A O l a b o d e . P h D ,
B . P h a r m a , M P S N , M C PA N

2. • Drugs don't work in patients who don't take them. - C.
Everett Koop
• This is the major problem– poor adherence to medication regimens reduces the
effectiveness of those treatments.
▪ Medication non-compliance ‘the world’s “other drug problem”
Remember this......

3. Defining Medication Adherence
• “The extent to which a person’s behavior (taking medication,
following a diet, or making healthy lifestyle changes)
corresponds with agreed-upon recommendations from a health-
care provider”
World Health Organization, 2003
“The patient’s conformance with the provider’s recommendation
with respect to timing, dosage, and frequency of medication-
taking during the prescribed length of time”
Agency for Healthcare Research and Quality
• Adherence to pharmacological treatment is a frequent issue in clinical healthcare
because, evidently, compliance with prescriptions is a prerequisite for treatment
efficacy.

4. Stages of Adherence
• Initiation stage: signifies the time from prescription until the patient
takes the first dose of the medication – does the patient take the first
dose as prescribed?
• Implementation stage: the period from initiation until the last dose is
taken-‘the extent to which a patient’s actual dosing corresponds to
the prescribed dosing regimen, from initiation until the last dose is
taken’.

5. • Discontinuation stage: demarks the end of therapy, when the patient
quits the last dose and no more doses are subsequently taken - which
is whether the patient takes the last dose as prescribed.
• Persistence is the length of time between the initiation stage and the
discontinuation stage.

6. • A patient can be non-adherent to their medication regimen if they fail
to collect and take their medication on time, if at all (described as
primary non-adherence);
• if they don’t follow the dosing regimen (a patient, over time, starts
to miss doses, prematurely stops the therapeutic course of action, or
takes incorrect doses) during the implementation stage (secondary
non-adherence);
• and if they discontinue the course early (non-persistence).

7. Types of non-adherence
• Unintentional non-adherence includes factors such as patients not
understanding how to take their medication, or forgetting to take
medications, or failing to pick up refills.
• Intentional non-adherence includes consciously discontinuing
treatment or self-modifying treatments (such as pill cutting or
reducing the frequency of doses without the patient consulting a
physician). Intentional non-adherence has been linked to patients’
negative perceptions of a medication.

8. Problem of non Adherence
• Clinical/Health Outcomes
➢ Poor therapeutic outcomes
➢ Further disease progression
➢ Decreased quality of life
• Economic Outcomes
➢ Increased costs to healthcare system
➢ Increased hospitalization
➢ Increased frequency of Emergency Department
visits
➢ Increased physician visits
➢ Loss of productivity
The Problem/Results With Non-Adherence

9. Reasons for Non-adherence
Fear
• Patients may be frightened of potential side effects. They may have
also experienced previous side effects with the same or similar
medicine. Additionally, patients report not taking their medication
because they may have witnessed side effects experienced by a friend
or family member who was taking the same or similar medication.
From seeing those side effects experienced by someone else, it may
have led them to believe the medication caused those problems.

10. Cost
• A major barrier to adherence is often the cost of the medicine
prescribed to the patient. The high cost may lead to patients not
filling their medications in the first place. They may even ration what
they do fill in order to extend their supply.

11. Misunderstanding
• Non-adherence can also happen when a patient does not understand
the need for the medicine, the nature of side effects or the time it
takes to see results. This is especially true for patients with chronic
illness—taking a medication every day to reduce the risk of something
bad happening can be confusing.

12. Too many medications
• When a patient has several different medicines prescribed with
higher dosing frequency, the chances that they are non-adherent
increase. Physicians can try to simplify a patient’s dosing schedule by
adjusting medicines so they can be taken at the same time of day.
Choosing long-acting drugs can also help if the dosing burden is too
complex. Additionally, if possible, consolidate medicines by using
combination products.

13. Lack of symptoms
• Non-adherence might occur when there is a lack of symptoms.
Patients who don’t feel any different when they start or stop their
medicine might see no reason to take it. Additionally, once a patient’s
condition is controlled, they may think the problem has resolved and
may discontinue using the medication. It is important to inform your
patient that they may need to take the medicine for a long time.

14. Mistrust
• With news coverage of marketing efforts by pharmaceutical
companies influencing physician prescribing patterns. This ongoing
mistrust can cause patients to be suspicious of their doctor’s motives
for prescribing certain medications.

15. Worry
• If a patient is concerned about becoming dependent on a medicine, it
can also lead to non-adherence. One way to overcome this is to
improve patient-physician communication. Inadequate
communication can account for 55% of medication non-adherence,
making it important to understand the patient’s rationale for
nonadherence.

16. Depression
• Patients who are depressed are less likely to take their medications as
prescribed. Physicians and other health professionals may be able to
uncover this by sharing issues and asking if the patient can relate to it.
To reduce embarrassment, express that many patients experience
similar challenges

17. Pharmacist Role
• Pharmacists are in a unique position to be readily available to answer
the questions of a patient.
• Pharmacists should never assume that a patient is adherent. Patients
should be assessed for adherence—ideally, at each visit

18. Pharmacist Role-5 Approaches
• Education
• Motivational Interviewing
• Address Specific Barriers
• Self-Management Training
• Making Taking Medication a Habit

19. Indication, Effectiveness, Safety & Adherence
• Indication Reason for taking medication
• Effectiveness What patient should expect
• Safety Potential side effects and/or interactions
• Adherence Cost, memory aids, swallowing problems
Education

20. Motivational Interviewing
Motivational Interviewing
Facilitate patient sharing his/her story
Active and reflective listening, positive affirmations
Explore importance and build confidence (e.g. engage in
“change talk”)
Make a change plan WITH the patient.

21. Understand the Patient’s Story
How do they understand their disease?
How do they understand their treatment?
Decisional balance:

22. Address Specific Barriers
• What might be specific barriers to adherence?
• A few patients will need true exposure treatment
(refer to behavioral health) for phobias (needles, taking
pills)
• Help patients set reminders if they are forgetful.

23. • Pharmacists should be cognizant of their patients’ health literacy,
consider implementing health-literacy assessments in their practice
so that patient education, counseling, and interventions can be
targeted appropriately. Educational interventions often resulted in
better adherence and improved medication knowledge.
• Self-efficacy enhancement is crucial to improving medication
adherence in patients with poor health literacy. (Self-efficacy is the
belief in one’s own abilities, particularly the ability to meet challenges
and achieve goals)

24. Motivational Interviewing
• Motivational Interviewing (MI) is a method of patient interviewing
structured to promote behavioral changes via “a set of targeted
communication skills to motivate patients to change their own
behaviors in the interest of their health.” MI aims to facilitate
collaboration between the patient and his or her provider while
respecting the patient’s autonomy. MI is used to explore the reasons
for barriers to medication intake. Compared with traditional
counseling approaches, MI is supportive (rather than argumentative
or coercive) and focuses on the patient’s intrinsic motivation.

25. • To use MI to improve adherence, the pharmacist should collaborate
with the patient to elicit change talk, set goals for taking medication
consistently, and work to resolve barriers to adherence. During these
activities, it is crucial for the pharmacist to demonstrate empathy and
rapport while educating the patient that change takes time,
particularly to successfully maintain this change in the long term. MI
has been demonstrated to support behavior change and improve self-
efficacy, thereby facilitating improvements in medication adherence

26. • Patients are more likely to be receptive to change when they feel that
they acting independently to make that change. To assist patients in
setting medication-taking goals to improve adherence, the pharmacist
should ask questions such as “Which strategy seems like something
you could try to increase your medication taking?”
• Prior to giving advice, the pharmacist should ask the patient for
permission; for example, “May I share with you some ideas that other
patients with diabetes/hypertension have tried to help them
remember to take their drugs/basal insulin?

27. • When adherence is being assessed, open-ended questions should be
asked to verify patients’ understanding of their prescription
medications. Any gaps in understanding can be corrected before the
patient leaves.

28. Three Prime Questions
• What did the prescriber tell you the medication was for? _ Name and
purpose of medication
• How did the prescriber tell you to take the medication? _ Dose, route,
frequency, storage, duration and techniques for use
• What did the prescriber tell you to expect? _ Positive effects expected
and what to do if they do not occur; possible side effects, how to
decrease likelihood of occurrence, and what to do if they occur

29. • Following completion of these questions, final verification of patient
understanding should be confirmed via the teach-back method (i.e.,
patient restates the information in his or her own words).
• To help patients feel more comfortable and lessen their
embarrassment if they miss or misinterpret information, the
pharmacist should always attribute the error to himself or herself. To
verify patient understanding, the pharmacist should say, “Just to be
sure I didn’t leave anything out, please tell me how you are going to
take this medication.

30. • When patients are asked to verbalize their understanding through use
of the three prime questions and teach-back, the covered information
becomes part of their long-term or gist memory, and the information
is retained longer compared with traditional or lecture-style
counseling.
• Periodic assessment of the patient’s understanding of how to take
long-term medications should be conducted, as misunderstanding
could influence adherence.

31. • Dosing simplification and minimization of adverse effects are
extremely successful strategies for improving adherence. When
filling a prescription, the pharmacist should do a quick review to see
whether the dosing schedule is as simple as possible. The
pharmacist should inquire frequently about any adverse effects the
patient is experiencing and then consult the physician regarding
suggested alternatives.

32. Conclusion
• While medication dispensing is the best-known function of the
pharmacist, pharmacists—through counseling, medication therapy
management (MTM), disease-state management, and other means—can
play a pivotal role in patient care and pharmaceutical care.
• There are opportunities in every type of pharmacy practice to improve
patients’ adherence and therapeutic outcomes, and pharmacists must
embrace and act on them.
• Many factors dictate a patient’s medication adherence, and each patient is
unique. The pharmacist must approach each patient individually to
determine the level of adherence and what barriers may exist that are
preventing the patient from taking his or her medication appropriately

33. THANK YOU
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