1. The Reality of Non-Compliance GreenPharmEdu.org

2. Non-compliance or Non-adherence Non-complianceoccurs when a patient fails to take medication as directed. Also called Non-adherence or Concordance There are many forms and subtleties, often these terms are used interchangeably.

3. Non-Compliance Purposeful deviation from prescribed directions Can be conscious or unconscious Under-adherence or over-adherence Major cause of wasted drugs Various sources site occurrence about 50%

4. National Council on Patient Information and Education Half polled said they had forgotten to take a prescribed medicine One third prematurely ceased treatment One quarter used less than recommended dose One third failed to fill prescriptions Enhancing Prescription Medicine Adherence: A National Action Plan http://www.talkaboutrx.org/documents/enhancing_prescription_medicine_adherence.pdf

5. Sorensen et al (2005) Medication management at home: medication risk factor prevalence and inter-relationships “The number of medications present in a home serves to reflect poor healthcare outcomes more reliably then the number of medications a patient is aware of taking.” Poor storage strategies and accumulated medications are strongly correlated with adverse healthcare outcomes. Sorensen, L. Stokes, LA, Purdie DM, Woodward M, Roberts MS, 2005, Medication management at home: medication risk factor prevalence and inter-relationships Journal of Clinical Pharmacy and Therapeutics Volume 31, Issue 5, pages 485–491, October 2006

6. Four common manifestations Forgot to take medications as directed Failed to fill a prescription Taking less then recommended dose or early discontinuation Substituting OTC in place of filling a prescription

7. Pound et al “We argue that peoples’ resistance to medicine taking needs to be recognized and that the focus should be on developing ways of making medicines safe, as well as identifying and evaluating the treatments that people often choose in preference to medicines Pound, P Britten, Morgan, M Yardley, L, Pope, C, Daker-White, Campbell, R (2005) Resisting medicines: a synthesis of qualitative studies of medicine taking. Social Science and Medicine, 2005 61(1): 133-155 https://files.pbworks.com/download/Peykf61J6W/europharm/19341793/Pound_2005%5B1%5D.pdf

8. Resisting Medications “Widespread caution about taking medicines highlighted the lay practice of testing medicines, mainly for adverse effects.” “The main reason why people do not take their medicines as prescribed is not because of failings in patients, doctors or systems. “On the whole, the findings point to considerable reluctance to take medicine and a preference to take as little as possible.” Pound, P Britten, Morgan, M Yardley, L, Pope, C, Daker-White, Campbell, R (2005) Resisting medicines: a synthesis of qualitative studies of medicine taking. Social Science and Medicine, 2005 61(1): 133-155 https://files.pbworks.com/download/Peykf61J6W/europharm/19341793/Pound_2005%5B1%5D.pdf

9. Medicines non-use in primary care Dislike by patient for using drugs Fear of becoming addicted to non-addictive drugs Fear of long-term adverse effects Distrust of physicians Belief that prescription is unnecessary Belief that that taking a medication confirms the illness Mackridge AJ, Medicines Non-Use in Primary Care. 2007; Aston University, Birmingham http://mackridge.com/wp-content/uploads/2008/12/complete-thesis-web.pdf

10. Costs Prescriptions costs are too high Desire to conserve medications for future use by hording, skipping doses or splitting does Costs high enough that consumers continue to hand on to medications beyond actual utility. Kennedy, J,& Christopher Erb, C (2002) Prescription Noncompliance due to Cost Among Adults With Disabilities in the United States, American Journal of Public Health | July 2002, Vol 92, No. 7 http://ajph.aphapublications.org/cgi/reprint/92/7/1120.pdf

11. Cover up Some patients continue to reorder medications in order to hide this lack of compliance! Auto-refills and mail order pharmacies make this worse! Braund, R.; Peake, B. M.; Shieffelbien, L.Disposal practices for unused medications in New Zealand, Environment International2009 Vol. 35 No. 6 pp. 952-955

12. Consequences of Poly-pharmacy As number of medications increases, so do non-compliance rates! One in four seniors take between 10 and 19 pills daily! Any number over three prescriptions is associated with greater non-compliance! Van Dusen, A (2009) Are you taking too many medications? Forbes.com, July 19 http://www.forbes.com/2008/06/19/health-drugs-prescriptions-forbeslife-cx_avd_0619health.html

13. Brown-bag Medication Review More effective drug usage is effected by awarenessfor both physician and patient. Linkages between drug life-cycle is key to reducing a variety of issues. Ask patients to bring in all their medications for a review-prescriptions and OTC Can reveal medications from other physcians Allows for dosage adjusting Builds collaborative ‘shared-decision making”

14. Asynchronous prescribing Patients with on several prescriptions have refill cycles out of sync. This can lead to over prescription or under-utilization Coventry Teaching PCT 2007 http://reports.pmetbtrainingsurveys.org/IndicatorScores.aspx?agg=AGG01|2007&groupcluster=5MD

15. Prescriber and Rational Prescribing Prescribers role have an impact. Are medications necessary? Are they over-prescribed? Physicians respond to the expectations of the patient Offers a clear conclusion to the consultation

16. Most significant is the knowledge of prescriber Physicians prescribe more then patients expect! When patients expected prescriptions, they were three times more likely to gain prescriptions for new conditions When physicians assume that the patient was expecting a prescription, the patient was 10 times more likely to be issued a prescription! Cockburn, J & Pit, S (1997)Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations—a questionnaire study. BMJ 1997; 315 : 520 http://www.bmj.com/content/315/7107/520.full