Transcript Medication adherence - UCSF School of Medicine

Practical Strategies for
Improving Medication
Adherence
Descartes Li, M.D.
Associate Professor of Clinical Psychiatry
University of California, San Francisco
[email protected]
7/16/2015
Medications don’t work
in patients who don’t
take them.
By the end of the seminar, a
participant will:
• Be able to list common reasons that individuals
stop taking medications as prescribed.
• Apply, in clinical situations, the “medication
menu” conceptual model of prescribing
medication for chronic disorders.
• Understand the Stages of Change model.
• Apply, in clinical situations, motivational
interviewing techniques.
Interventions to Improve
Adherence
Almost all studied interventions that are effective
for long-term care are complex:
• more convenient care
• information
• counseling
• reminders
• self-monitoring
• reinforcement
• Family therapy
Interventions to Improve
Adherence
In a comprehensive review,
Only 49% of the interventions tested (19 of 39 in 33 studies)
had statistically significant increases in medication
adherence and
Only 17 reported statistically significant improvements in
treatment outcomes.
Even the most effective interventions had only modest
effects.
Conclusions: Current methods are mostly complex, laborintensive, and not predictably effective.
Macdonald HP et al. JAMA. 2002;288:2868-2879
Case Vignette:
A frustrating patient
AB is a 64 year old widowed woman with HTN and
depression. She is on multiple anti-hypertensives. For
the past year, whenever she presents to clinic, her
blood pressure is quite high (ranging from 165190/85-95).
Unclear if she actually takes her meds, but she states
that she doesn’t always take all of them. She doesn’t
like being on so many medications. She always comes
to her appointments.
You are reluctant to increase doses or add medications
lest she take all of them and drop her blood pressure
too fast; yet, you are concerned about her stroke risk.
Practice interview
Find a partner
One person is the “Frustrating Patient”, the other is
the “Doctor” (three is ok with one Observer)
Start with trigger question:
“What do you think about your blood pressure?”
What feelings developed in the Doctor?
Outline:
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Clinician Attitudes
Epidemiology
Reasons for Non-Adherence
The “Medication Menu” Approach
Stages of Change
Motivational Interviewing
Clinician Attitudes
• Better therapeutic alliance predicts better adherence
(1).
• Patients who are non-adherent are frequently
frustrating and demoralizing to work with.
• Remember that non-adherence is the norm.
• What kinds of thoughts/feelings are generated by
patient nonadherence?
1. Tuna A et al: Therapist characteristics and outcome of treatment of schizophrenia.
Archives of Gen Psychiatry 1978; 35:81-85.
Clinician Attitudes
Feelings/thoughts generated by patient nonadherence:
• “The patient is being resistant/passive-aggressive.”
(Challenge to doctor’s authority)
• “The patient is manipulative and does not want to get
better.” (blaming)
• “What could I do about it? The patient just did not
cooperate with my treatment plan.” (Distancing)
• The Challenge: Assuming the appropriate amount of
responsibility for treatment “noncompliance” or failure.
How does this affect our behavior?
Manifestations of clinician
attitudes
• We feel hopeless about medications and prescribe
medications we know the patient will decline.
• We minimize or ignore patient’s complaints of side
effects.
• We lecture the patient on the importance of taking
the medications “as prescribed.”
• We develop an overly confrontative style with the
patient.
• We terminate treatment with the patient for noncompliance.
How can we convey that we are
“with” the patient, rather than
against them?
• Decreasing the patient’s sense that we are pressuring
them paradoxically often leads to an increase in the
likelihood that the patient will take the medication.
• “Resistance occurs when the patient does not
do what the physician wants…and when the
physician does not do what the patient
wants.”
• “Patients are not noncompliant. Physicians
are.”
Outline:
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Clinician Attitudes
Epidemiology
Reasons for Non-Adherence
The “Medication Menu” Approach
Stages of Change
Motivational Interviewing
How common is medication nonadherence?
• Poor medication adherence:
“America’s other drug problem”
– Vastly understudied relative to extensive literature on
the effectiveness of pharmacotherapies
• Costs and outcomes
– Adherent patients: 50% lower hospitalization risk, up
to 50% lower healthcare costs, lower suicide risk
– Bipolar
• Typically associated with co-morbid conditions
• 50% or more take 4 or more chronic medications
Disease Prevalence
Average Reported Rate Of NonAdherence Is 43%
Reported rate of non-compliance
Source: Manhattan Research 2004 data
What’s At Stake? - Medication
Non-Adherence Drives Up
Healthcare Costs
Failure to take medication as prescribed:
 Causes 10% of total hospital admissions
 Causes 33% of CHF hospital admissions
 Causes 75% of Schizophrenia admissions
 Causes 68% of NNRTI resistant/mutated HIV
virus
 Results in $100 billion/year in unnecessary
hospital costs
 Causes 22% of nursing home admissions
 Costs the U.S. economy $300 billion/year
(N Engl. J Med 8/4/05, National Pharmaceutical Council, Archives of Internal Medicine, NCPIE,
American Public Health Association, AIDS 2006 20:223-232)
The Medication Adherence Solution
Outline:
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Clinician Attitudes
Epidemiology
Reasons for Non-Adherence
The “Medication Menu” Approach
Stages of Change
Motivational Interviewing
Case Vignette
CD is a 64-year-old married man with severe
asthma and COPD. He is chronically dyspneic
but is very erratic with inhaled corticosteroids.
He will take both inhaled corticosteroids and beta
agonists, but only on a as needed basis. He has
stopped smoking for two years, but has a 50+
pack-year hx. His EKG shows right-sided
changes.
You are concerned about long term effects of
undertreated asthma and COPD.
Practice interview
Start with trigger question:
“What do you think about your asthma?”
What were the reasons for non-adherence?
Reasons for Non-adherence
Self-regulation and Testing the Illness
The Meaning of Medications and Stigma
The Addiction Myth and The Crutch Metaphor
Ambivalence and Denial
Fear of Medication and Its Side Effects
Other risk factors: age, cost, low self-efficacy
Self Regulation and Testing
Self-regulation as opposed to adherence:
About half of people who are non-adherent perceive
themselves as simply adjusting their own meds.
Why do people vary their medication regimes?
Self-regulation
*alcohol
Testing (“Am I ill?”)
Conrad P. The Meaning of Medications: Another Look at Compliance. Soc Sci Med.
20(1), pp29-37, 1985.
The meaning of medications
and stigma
“What does it say about me that I have to take this drug?”^
• “I am sick!”
• “Oh God, not this again.”
• “I am defective.”
Can we replace these negative thoughts with more positive
ones?
• No, only the patient can (but we can make suggestions)
Can we instill hope in every patient?
• No, but we can help them come to terms with their
illness.
What kinds of thoughts go through your mind when you
take these meds? (behavioral incident technique)
Pills come with thoughts
• Understanding loss:
– For some patients, medications symbolize hope (a
ticket to normality)
– For others, they symbolize despair and loss, a constant
reminder that their lives will never be the same again
“I can’t put up with this anymore. I just don’t give a
damn.”
• Stigma
– “People with illness A are _______.”
– Taking medications acknowledges the illness and
therefore, whatever stigma is associated with the illness
The Addiction Myth and the
Crutch Metaphor
The patient asks: “Are antidepressants addicting?”
• Should you wait until the patient asks?
• Defining/differentiating from “withdrawal”.
Related to the Crutch Metaphor.
• The patient states: “I don’t want to use a crutch.”
• “Am I a self-reliant individual?”
How do you address these concerns?^
Dealing with Denial: Am I ill?
Question: When would you take insulin or an
corticosteroid or an antipsychotic?
Answer: Only if you were pretty sure something
very serious was wrong with you.
Similarly, patients are making the best decision they
can, given their beliefs at the time. (remember:
patients takes medications because of their beliefs,
not yours.)
N.B.: Particular disorders in which patients often do
not think anything is wrong with them.
Addressing “Do I have an
illness?”^
• Illness is indirectly addressed by development of a
goals (aka “Inquiry in to Lost Dreams”)
– What does (disease) prevent you from doing that you
would really like to be able to do?
– Doing it for the family. (can develop affirmations:
“this is for my daughter.”) or picture of family next to
pill box.
• Elicit examples of family members/significant
others with the disorder.
Dealing with Ambivalence
If the patient is ambivalent, don’t push too hard.
Once a patient has started a medication and then stopped,
it is very difficult to get the patient to re-start same
medication again. (Pt has to admit that they were wrong
to stop in the first place.) – see “Stages of Change”
“I actually think it might be better not to make a decision
today. Why don’t you think about it, talk it over with
you spouse or friends, and next time we can talk about it
again.”
“There’s no reason to rush a decision. Here is some more
information on the medication. Read it and see what you
think. Does that sound okay to you?”
Medication Sensitivity
Will the medication harm me?
“Doctor, I am very sensitive to medications.”
“Hey, you’re really not sensitive. Those are just common
side effects.”
• What do you think the patient hears?
• Other potential responses?
• “Given your sensitivity to medications, which are not
uncommon by the way, I’d like to suggest that we start
with a really low dose, a baby dose, of the medication.
What do you think?”
Technique: exploring medication
sensitivity
1. “Do you think you are particularly sensitive to
medications?”
2. Explore patient’s perspective: “What are some
of the things that have happened that have
shown you are particularly sensitive?”
3. Do not challenge patient’s perspective on
medication sensitivity.
4. Ask patient permission to start at a “baby dose”.
Remember to give rationale.
Side Effects
• “No patient has ever stopped a medication
because of a side effect, unless the side effect
killed him.” (Shea)
• Importance of perception
Outline:
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Clinician Attitudes
Epidemiology
Reasons for Non-Adherence
The “Medication Menu” Approach
Stages of Change
Motivational Interviewing
Outline
1. Assess clinical situation
2. Negotiate treatment plan
Develop “menu” of options
Review options
Collaboratively agree on an option
3. Evaluate outcomes
4. Go back to 1.
Negotiate the treatment plan
• Use negotiating skills!
• You may have to compromise but make sure that
outcome will be remembered or recorded and
thereby influence future choices.
• Check to make sure that the patient understands
and is in agreement with the plan.
Outline:
•
•
•
•
•
•
Clinician Attitudes
Epidemiology
Reasons for Non-Adherence
The “Medication Menu” Approach
Stages of Change
Motivational Interviewing
Stages of Change
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Pre-Contemplation
Contemplation
Preparation
Action
Maintenance
Resistance
• Readiness to change is not a trait, but a
fluctuating product of interpersonal
interaction.
• Resistance and ‘denial’ are not traits, but
are feedback regarding physician
behaviour.
• Resistance is often a signal that the doctor
is assuming greater readiness to change
than is the case,
• And it is a cue that the counsellor needs to
modify motivational strategies.
Pre-Contemplation
Not considering change or is
unwilling/unable to change
Contemplation
Acknowledges concerns and is
considering change but is
ambivalent and uncertain
Committed to and planning to
make a change in the near future
but is still considering what to do
Actively taking steps to change
but has not yet reached a stable
state
Has achieved initial goals and is
now working to maintain changes
Preparation
Action
Maintenance
Case Vignette
EF is a 48-year-old married woman with FBS = 160
and her HbA1C = 9 and BMI = 30.9 (ht = 5’4”,
wt = 180lbs).
A 6m trial of diet and exercise produced no change
in weight or labs.
She says: “I know diabetes is a serious illness, but I
really don’t want to take diabetes meds. My
mother was on diabetes medications, then insulin,
but she still died of kidney failure.”
Practice Interview
• What stage of change is she at?
• Trigger question:
What would you like to do now about your blood
sugars now?
Outline:
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•
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Clinician Attitudes
Epidemiology
Reasons for Non-Adherence
The “Medication Menu” Approach
Stages of Change
Motivational Interviewing
Motivational Interviewing
• Motivational interviewing is an interpersonal style,
not merely a set of techniques
• Motivation to change is elicited from the patient, and
not imposed from without.
• Primary clinician task is to facilitate expression of
both sides of the ambivalence impasse.
• The counselling style is generally a quiet and
eliciting one.
• The therapeutic relationship is more like a
partnership or companionship than expert/recipient
roles.
• The doctor respects the patient’s autonomy and
freedom of choice and consequences regarding his or
her own behaviour.
Motivational Interviewing
• Interviewing style
elements:
Ask open-ended
questions
Conduct empathetic
assessments
Discover client’s
beliefs
Reflective listening
Motivational Interviewing
(continued)
• Motivating strategies:
Normalize doubts
Amplify doubts
Deploy discrepancy
Support self-efficacy
Review past treatment
experiences
©2002 Microsoft Corporation.
What is Self-Efficacy?
• Belief in the possibility of change
• Patient is responsible for choosing and carrying
out personal change
• There is hope in the range of alternative
approaches available
Miller and Rollnick 1991
Motivational Interviewing
(continued)
• Motivating strategies (continued):
Provide relevant feedback
Summarize sources of non-adherence
Negotiate proximal goals
Discover potential barriers
Display optimism
Involve supportive significant others
©2002 Microsoft Corporation.
Motivational Interviewing
Precontemplation
• Stay engaged with the patient: regular visits,
maintain interest
• Ask permission: Would it be okay if we talked
about your blood sugars?
• Keep the issue alive:
– Elicit patient’s perceptions of the problem
– Examine discrepancies between patient’s and others’
perception of the problem
– Continue to educate patient (check for areas of
knowledge deficits)
– Help significant other to intervene
Motivational Interviewing
Contemplation
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Normalize ambivalence (ie, indecisiveness)
Discuss pro’s and con’s (hint: take the con’s side)
Summarize arguments/obstacles.
Ask about patient’s perceived self-efficacy
– How likely do you think this will work?
Motivational Interviewing
Preparation
• Offer menu of options for treatment and negotiate
treatment plan
• Find out what worked the past, and what didn’t
• Anticipate and help lower barriers (eg, cost,
family, convenience)
• Enlist local supports (family): have patient
publicly announce plans
• Explore patient expectations
Motivational Interviewing
Action
• Reinforce importance of patient’s commitment
and perseverance.
• Acknowledge difficulties in early stages
• Identify with patient future obstacles
• Assess social supports (or problems)
Motivational Interviewing
Maintenance
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Affirm patient’s adherence and self-efficacy
Maintain supportive contact
Develop plan for non-adherence
Review long term goals and reasons
Case Vignette
EF is a 48-year-old married woman with FBS = 160
and her HbA1C = 9 and BMI = 30.9 (ht = 5’4”,
wt = 180lbs).
A 6m trial of diet and exercise produced no change
in weight or labs.
She says: “I know diabetes is a serious illness, but I
really don’t want to take diabetes meds. My
mother was on diabetes medications, then insulin,
but she still died of kidney failure.”
Practice Interview
• Assume she is at the Contemplation stage.
• What Motivational Interviewing techniques would
you like to try?
Feedback and Summary
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Clinician Attitudes
Epidemiology
Reasons for Non-Adherence
The “Medication Menu” Approach
Stages of Change
Motivational Interviewing
References
Shea, SC. Improving Medication Adherence. Lippincott
Williams &Wilkens. 2006.
McDonald et al. Interventions to Improve Medication
Adherence. JAMA, December 11, 2002—Vol 288, No.
22.
Haynes RB et al. Interventions for enhancing medication
adherence. The Cochrane database of systematic reviews
2008 issue 2.
“TIP 35: Enhancing Motivation for Change in Substance
Abuse Treatment” Call U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES at (800) 729-6686
for a free copy