Monday, January 31, 2005

When meds stay in their med-boxes

What can be done for patients who don't take meds as prescribed, even when they know that the consequences are life-threatening? Dr. Robert Steiner MD has a CME activity at Medscape that addresses this problem. It's written for organ-transplant teams, but most docs could insert their own specialty here.

Much of the medication noncompliance observed in transplant recipients would not appear to be rational, which is why it can be so difficult to modify by straightforward educational measures.[62] But in an attempt to understand this behavior, noncompliant patients have been categorized in the following way[6]:

• "accidental" noncompliers: disorganized to the extent that taking their medications is not a high priority;

• "decisive" noncompliers: have well-considered rationales for their noncompliance;

• "immortal" noncompliers: do not defend their noncompliance but are guided by unarticulated, unrealistic beliefs and fears.
...Noncompliance that is not irrational or otherwise based on psychopathology might be amenable to patient education and other straightforward strategies to modify behavior. When patients are first transplanted, they are arguably most susceptible to caregivers instilling in them compliant attitudes and practices.[5] However, over time they develop a false sense of security during a relatively benign early postoperative course[5,55] when the frequency of scheduled follow-up visits decreases, when physicians under-react to early overt signs of noncompliance and reduce doses "under pressure" from the patient, and when anxious medical staff give nonconstructive feedback when patients are noncompliant.[64] (emphasis added.)From the patient's perspective, if nothing bad has happened to their graft thus far, and if the medical staff do not appear particularly concerned about graft loss, including maintenance of adequate drug blood levels, why should they be so meticulous? The end result is often noncompliance.[65,66]
Unintentionally, we can send a message that missing a few meds is "no big deal."

What if the patient can't afford meds? Free meds boost compliance, but not as much as you'd think. This is also evident in our clinic, where large numbers of patients get their meds through Patient Assistance Programs.
Much noncompliance may stem from deeply ingrained beliefs and fears that the patient does not completely recognize and that are therefore difficult to address. The preceding considerations should make it clear that many patients do not exactly "choose" to be noncompliant; rather, they cannot entirely help themselves to do what is manifestly the right thing. Therefore, use of scare tactics and other punitive measures by caregivers may only make the interaction unpleasant and unproductive. It may compel the patient to avoid contact with caregivers, to dissemble ("white coat compliance"), and/or not to try to face up to deep-seated compliance problems. During regular visits, caregivers should encourage patients to express their thoughts to get an idea of whether patient compliance is affected by a fundamental denial of clinical reality, irrational fears of side effects or the medical environment, adverse reaction to authority, feeling of powerlessness, anger at caregivers or others, belief in unsubstantiated alternative therapies, overt depression, or mania. Identifying and dealing constructively with these root causes of irrational noncompliance are challenges to clinicians.

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