MEDICATION ADHERENCE

One of the most broadly applicable behaviors in primary care in which motivation plays a dominant role is with medication or treatment adherence. Poor adherence to a medication regimen can be a source of poor health outcomes and potentially lead to significant increases in expense and risk through the need for second-line treatments, which may take the form of more invasive procedures, surgery, or brand-name drugs.

This process uses more healthcare resources and drives up costs while positive out-comes lag. Lack of adherence without an understanding of why it is occurring can also lead to discord in the relationship between the patient and the trainee as they expect the patient to make changes that he or she may not wish to make.

Increasing motivation for medication adherence can be difficult for some patients because the rewards are often so far removed from the effort. For example, adequate control of hypertension comes with well-established benefits as risks of stroke or heart failure are reduced. While patients may be aware of these negative outcomes

129Motivational Interviewing in Primary Care and understand that the point of the medication is to avoid them, the actual nega-tive outcomes are usually decades removed from the act of taking daily medication, some of which must even be taken several times a day. This is particularly true when the disease, such as hypertension, is silent and causes no immediate discomfort or symptoms. Modifying behavior when the activity seems so trivial in relation to an out-come that is very far removed can be challenging for some patients. MI can be helpful for addressing this aspect of treatment because of its emphasis on openly exploring readiness, willingness, and confidence for making behavior changes. During this pro-cess, patients may discuss their struggle about understanding how taking medication is important to staying healthy. When this occurs, the trainee can reflect metaphors related to the patient’s personal experience to illustrate the importance of taking medi-cation as prescribed. For example, with patients who play sports or music, the trainee can discuss the gradual improvement that comes with daily practice. Consistent prac-tice is necessary in order to perform at optimal levels. Similarly, the quality of our health is the cumulative effect of our daily regimens of avoiding risk-related activities while engaging in exercise, making good dietary choices, and adhering to medication regimens.

Some important points to remember in guiding your patient include assessing rea-sons for nonadherence. Barriers may be psychological or practical. A patient may be skipping doses because he or she feels unconcerned about the underlying health issue, or he or she may not be following your prescribed plan because he or she has financial difficulties with obtaining the medications or concerns about a side effect. Screening questions for medication nonadherence have very low sensitivity. It is more useful to ask patients about possible side effects of their medications using open-ended ques-tions. Provide information (after asking permission) on side effects if the patient is unaware or has inaccurate information and encourage him or her to contact you or return if problems arise. Using the E-P-E framework can be very helpful to explore adherence challenges.

Do your best to prescribe drugs with the fewest daily doses possible since adher-ence drops off rapidly when patients are expected to take medications three or more times a day. Discuss costs with the patient while prescribing and balance priorities;

long-acting medications require fewer doses but are often more likely to be under pat-ent and may be more expensive. When there are multiple formulations with vary-ing cost, allow patients to choose which formulations they want, as this will enhance adherence. Be familiar with common insurance plans and be comfortable working within that framework. Many plans have limits on drug benefits. Prescription drugs may rapidly deplete this amount, even if the patient is initially paying nothing out of pocket. Learn about local, reduced-price programs and identify lists of discount ($4/$10) medications at major pharmacies. These can save money for both insured and uninsured patients. These lists typically include generic statin medications and antihypertensives. Maintain a sense of the challenges posed to patients on low or fixed incomes. A 90-day prescription may be cheaper to fill over time than three 30-day supplies. A medication with a $10 copayment per month may be discounted to $25 for a 3-month supply. However, patients who struggle financially often prefer to pay $10 each month than to pay $25 at one time, which can be beyond their means. Give the patients options and let their concerns guide your mutual decisions. It can be useful to ask yourself, “Am I retaining a sense of quiet curiosity about what will work best for this person?” (Miller & Rollnick, 2013).

Motivational Interviewing130 When available, it can be useful to corroborate refill information with the phar-macy’s records via an electronic health record (EHR). Address any discrepancies in an even-toned, empathic nonconfrontational manner, such as “I see you did not get the medication we talked about last time. What do you make of that?”

Exchanging Information

Education is an ongoing process and can be achieved in a way that is MI adherent.

Key elements include assessing each patient’s understanding of which medication(s) addresses which problem(s), as well as his or her understanding of the disease or condition and possible outcomes, both with and without treatment. It is critical that you explore patient expectations and verify that each patient understands and agrees to his or her treatment plan. Establishing a mutual purpose includes collaborating to define clearly stated behavioral goals on which both the trainee and the patient agree.

Many healthcare plans now provide tracking information (e.g., feedback on treatment impact, such as test results available) to patients, including electronic access when pos-sible, so patients can personally evaluate their own progress. Trainees should empha-size the value of this resource because it promotes the efficient provision of feedback.

Furthermore, self-reliance associated with using Internet-based information rein-forces patient responsibility for learning about his or her health status. The use of these resources represents a method beyond following up with the physician for additional feedback and increases the chance that changes will be implemented and will lead to better health-related outcomes.

There are often many opportunities to address inadequate or incorrect information.

For example, patients may not consider the impact of calories imbibed through soda, juices, milk, or alcohol. Americans consume on average more than 200 calories per day from sugary drinks, a four-fold increase since 1965. A reduction in daily soda intake or a switch to diet sodas, carbonated water, or unsweetened teas can offer some patients a simple starting point that enables them to envision that change is possible. Often the conception of an appropriate portion size is significantly skewed toward larger amounts, and assessing patient knowledge about portion size and offering information about it can be useful.

Patients may have concerns that are not supported by the literature. As stated by one cola-drinking patient with diabetes when given a recommendation to switch to diet cola, “That stuff will give you cancer.” One response might be a reflection such as “You’re really concerned about how it could affect your health.” Another might be asking permission to educate or advice by asking, “Would it be alright if I shared with you what we now know about diet drinks and cancer?” When permis-sion is granted, you can provide information such as “Some early animal studies raised significant concerns about artificial sweeteners and cancer, but large studies in people haven’t found any increased risk. In fact, evidence has linked sugared soda with pancreatic cancer, and there is rapidly growing evidence of increased cancer risks with obesity.” After providing this information, it is important to ask for feedback on the provided information by saying: “What’s your perspec-tive on that information?” The E-P-E framework is again applicable in exchanging information.

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Barriers to Treatment Plan Adherence

Encouraging communication about side effects or cost concerns can prevent patient-initiated discontinuation of a treatment. Ask each patient what might cause him or her to discontinue treatment and problem-solve in advance how to manage such situ-ations. Problem solving should be done in an MI-adherent manner. Ideally, elicit first from the patient his or her own ideas on how to solve problems with medication and affirm his or her resourcefulness. If the patient does not come up with ideas on his

Box 10.2 OARS Skills in the Context of Medication Adherence Open-Ended Questions

• “What do you find most challenging about getting/taking your medications?”

• “How did you feel when you realized you’d missed a dose of your medication?”

• “What are three things you do to help yourself take your medications?”

• “What ideas do you have for improving your consistency with taking your medications?”

• “What changes can we discuss together that might make it easier to take your medication?”

Affirmations

• “You have a lot of great ideas about how to improve the way you take your medication.”

• “You’ve put an incredible amount of work into trying different methods for tak-ing your medications regularly.”

• “Thank you for being so honest about how hard it has been to take your medication.”

• “You work very hard to make sure you take your medication regularly despite your mixed feelings about taking them every day.”

Reflections

• “You’re concerned about the effects that taking multiple medications may have on you.”

• “You don’t think this approach is going to be affordable for you.”

• “It’s not easy making changes to your daily routine so you can take your medication.”

• “Sometimes it just doesn’t seem worth it to take all these medications when you already have (add condition here). The damage is done.”

Summarizing

• “You find it difficult to take your medications on time, you’re struggling with some side effects, you’re being pressured by your family to take them consis-tently, and you don’t want to depend on them.”

• “You worry about the costs of your medications and you cannot afford the co-pay, you see the importance of not missing any doses, and you are very much conflicted about how to deal with this situation.”

Motivational Interviewing132 or her own, offer, with permission, suggestions such as pill boxes, cell phone alarms, automated e-mail reminders, and selecting particular drugs based on cost or number of doses needed per day. Although trainees should not recommend family involve-ment if the patient is not allowing it, some patients welcome their families’ help with reminders, or even maintaining control of medication.

Importance and Confidence Rulers

The rulers are used to assess and bolster medication adherence using a mixture of OARS skills (see Box 10.3).