Abstract Medication non-adherence is starting to become a major public health problem and is even called an invisible epidemic because

if non-adherence were a disease, it would be classified as such. Medication non-adherence is the driving force between 33% and 69% of medication-related hospital admissions as well as the cause of approximately 125,000 deaths per year in the US (Bosworth, H. B.). In addition to the health-related issues, non-adherence to medication regimens is the cause of costs ranging from $100-$300 billion dollars per year due to factors such as increased doctor visits, hospital admissions, and medications. To put this into perspective, the United States spends about $750 billion dollars every year on wasted health care. This paper examines the trends in medication non-adherence and explores the areas in which pharmacists can better intervene to prevent this problem. Medication non-adherence is not a problem that is caused by the healthcare system directly but it is one that can be prevented if the system takes the proper steps. Pharmacists play a unique role in the health care system and have specific knowledge and skills that can allow for them to tackle the problem in potentially very effective ways. Introduction Medication adherence is the extent to which patients take their medications as prescribed according to their medication regimen. The importance of medication non-adherence lies in the fact that chronic diseases are the leading cause of morbidity and mortality in the United States today, accounting for 70% of all deaths (Saimi). Approximately 50% of patients taking medications for chronic diseases/conditions are non-adherent and this often results in worsened disease states, reduced quality of life, early mortality, and more. In other words, the long term therapeutic benefits and efficacy of medications is dependent upon adherence to the prescribers instructions. However, medication adherence still shows to be a challenge in a significant population which prevents these individuals from receiving maximal therapeutic benefits that would give them a better quality of life. Adherence measures of the United States have often shown poor results which is very troubling. In these measures, adherence rates are reported as the percentage of the prescribed doses of medication actually taken by a patient over a specified time period. The major disadvantage to measuring adherence is that there is no method which should be considered a standard for doing so. The two general categories for measuring adherence are direct and indirect measurements. Direct measurements, those such as detecting drug levels in biological fluid and directly observing the patient, are highly impractical so indirect methods are more commonly used. These methods involve those of medication monitoring, self-report measures, prescription claims data, and more. Medication monitoring involves pill counts or electronic monitoring devices which record when the medication/dosage form is accessed. Self-reports can take the form of diaries or surveys (through phone, mail, or in-person). Prescriptions claims data are often used because it is easy to access data and see when patients with chronic conditions have discontinued taking their medications by seeing when they stopped refilling their medications. All of these methods have their own advantages and disadvantages which is why it is said that there is no standard for the measurement of medication adherence.

However, the profession of pharmacy allows for individuals in the healthcare profession to more directly gauge medication adherence in a way in which others cannot do so. Pharmacists are the last interaction many patients have after leaving health care facilities and before resuming their normal, daily lives. In addition, many health care professionals cannot, and more often, do not have the time to see whether or not patients on long term medications are getting refills in timely manners and this is the main indication as to whether or not patients are following their therapeutic courses as dictated by their doctors. Counseling is also effective between pharmacists and patients as it allows for pharmacists to explain the benefits and importance of adhering to medication schedules in addition to giving the patient a sense of empowerment through knowledge of their medication. Pharmacies have the ability to intervene and improve adherence rates and thus reduce, if not eliminate, the problems that arise with non-adherence. Patient Safety and Spending Concerns Medication non-adherence includes delaying prescription fills, failing to fill prescriptions, cutting dosages, and reducing the frequency of administration (Bosworth, H. B.). Any of these tendencies are very detrimental since they reduce the therapeutic benefits one can obtain from medication. The reach of this invisible epidemic is outstandingly large and in one case Cutler and Everett give an example of how better adherence to antihypertensive treatment alone could prevent 89,000 premature deaths in the US annually (Cutler). Antihypertensive medications aim to prevent strokes and are the major means of doing so in hypertensive patients. In a 12-year population based study involving 73,527 hypertensive patients conducted by Herttua, 2,144 died and 24,560 were hospitalized both due to stroke. This study also revealed that non-adherent patients had about three times higher odds of stroke death when compared with adherent patients (Herttua). Antihypertensive treatment is unfortunately not the only kind which is negatively affected by medication non-adherence. Medication non-adherence is also the cause of many situations such as frustration (by patient, physician, or both), incorrect diagnoses, and sometimes even incorrect treatments and increased chances of undesirable side effects. Another major problem with medication non-adherence is that failure to identify and remediate poor adherence often results in intensified pharmacotherapy with increased doses of medication (Bosworth, H. B.). This leads to increasing the potential risk of adverse effects associated with such higher doses. In many severe/intensive diseases, discontinuing medications for even brief periods can cause major setbacks in terms of progress/recovery. One example of such a disease and corresponding therapy is that of Schizophrenia and anti-schizophrenic medication. Hatfield describes discontinuation of a therapeutic course in the disease and talks about how one of the most frustrating problems faced by families is their relative's failure to adhere to the medications that have been prescribed Once medications have been discontinued, patients often become psychotic again and often cycle back into the hospital (Hatfield). In addition to the health concerns associated with non-adherence, there are many financial issues involved with non-adherence. Although one may initially think that picking up refills less than one is told to might save the patient money, it is usually the opposite which holds true. As mentioned earlier, intensified pharmacotherapy with increased doses is often associated with increased overall cost of

treatment. There are also many other results of non-adherence that are associated with increased costs such as unnecessary disease progression, disease complications, reduced functional abilities, lower quality of life, increased physician office visits, hospitalizations, nursing home admissions, and premature death (Testman). All of these outcomes lead to increased and, more importantly, avoidable/unnecessary spending from both the patients and the healthcare systems. It has been calculated that these costs due to non-adherence account for 13% of total healthcare expenses. Sources of the Problem The reasons behind poor medication adherence are often multifactorial and can be intentional or completely unintentional. Patients may choose to discontinue medications willingly due to factors such as drug expenses, adverse effects, and any other sort of risk-benefit analytical reasoning. At the same time, patients can also unintentionally deviate from their therapeutic course by forgetting to adhere to their mediation or being careless in taking it and following their prescribers instructions. Bosworth speaks of how the main factors of non-adherence include adverse effects or other problems with medications, such as poor instructions, poor memory, inability to pay for medications, and poor relationships between patients and health-care providers polypharmacy, low literacy, depression, and substance abuse pill burden, regimen complexity, side effects, duration of needed treatment, and dosing (Bosworth, H.B.). In other words, medication non-adherence is like a disease, or epidemic, in itself but it is a complex one which has multiple causes with no single cure or treatment. It is highly individualized and varies from patient to patient and as such must be handled in a correspondingly individualized manner. This is where pharmacy comes in to the picture and allows for personalized intervention with the issue of non-adherence. The Role of the Pharmacist and Methods That Should be Applied Universally Although pharmacists are a source of vast knowledge on drugs and medications, their jobs are still often viewed as that of simply dispensing medication. Over the years however, pharmacists have begun taking greater roles in patient care to help prevent issues such as that of medication nonadherence from negatively affecting both patients and the healthcare system of which we are all a part of. Pharmacists are not liable for medication adherence outside of healthcare facilities as it is not possible to observe the patient during his or her individual lifestyle but it is still something that pharmacists should be concerned about. In many cases, pharmacists are the last point of contact patients have with health care professionals after leaving health care facilities and returning to their everyday lives. Additionally, patients that have chronic diseases must see pharmacists every time they get refills on long-term medications. With these factors, Pharmacists have the ability to 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 (Albrecht). Counseling is an extremely effective approach towards improving medication adherence as pharmacists can intervene at any point a patient gets a refill on a long-term medication or even when a patient gets a new prescription. Many pharmacies such as CVS/Pharmacy have started a system in which employees must ask customers if they want counseling from a pharmacist when new prescriptions are

filled. The advancement of technology allows for ease of identification for new prescriptions. Such technology also allows for pharmacists to see when patients on long term medications are past-due for refill. This allows for pharmacists to easily identify non-adherent behavior among patients and provides the opportunity for intervention. Education is also very important in medication adherence because making sure a patient understands both the importance of his or her medication and has a thorough understanding of how it is used are strong contributors in guaranteeing voluntary/intentional medication adherence. Luckily, technology allows for pharmacists to educate patients with the use of effective labeling/packaging and with simplified diagrams in examples with those who have lower levels of reading comprehension or literacy. Follow up phone calls and reminders are also key methods of intervention for pharmacists in medication non-adherence. Phone calls allow for pharmacists to answer questions, follow up with patients with many medications or complex regimens, and follow up with patients who have not refilled medications to ensure that they have not been told to discontinue the medication by their prescribers. Conclusion: An Analysis of the Pharmacists Current Role and Going beyond Expectations Although pharmacists nationwide are already taking general steps towards preventing medication non-adherence, there is still much more that can be done. Identification of the sources of this problem and working to stop the problem at the sources is vital in ensuring medication adherence. Just as there are programs and initiatives working toward decreasing medication adherence, there are still potential sites for intervention not being utilized. This may be because of the rarer case in which pharmacists have sites of intervention but choose not to take advantage of these just because they would rather get the patient out of the store with their medication(s). Personally, I have seen this with a few pharmacists and it is something upsetting that needs to be handled through observations and performance evaluations. Luckily this is not the case with most pharmacists as they recognize their duties to the patients quality of life and the healthcare system as a whole. The major practice that needs to be implemented in pharmacies to prevent medication nonadherence to a greater degree is that of specialized programs. As mentioned earlier, there are many ways in which pharmacists can intervene to ensure patients are adhering to their medications. However, pharmacies have the ability to take these generalized practices to create even more specialized and, in a way, more individualized plans or programs. Many pharmacies have already incorporated specialized programs for the prevention of medication non-adherence. One for example is CVS Pharmacy Advisor program which is a unique approach to help patients with chronic conditions achieves better health outcomes by promoting improved medication adherence and closing gaps in care (Advancing Medication Adherence). Some programs adapt to societys rapidly evolving technology and their increasing dependence on this technology. One such program is a mobile app service which gives users instant access to features including reminders that can be set for consumption and refills, doses that can be logged, data logs that can be accessed by patients or uploaded to care providers, and medication information (Dayer). There are many other programs that focus on key intervention sites for patients such as how smart phone apps focus on the growing use of technology. Pharmacists have the ability to identify the

barriers to medication adherence and thus target them. They can stop the problem at its source to improve efficacy of long term medications, decrease unnecessary costs for both the patient and the healthcare system, and give patients the better quality of life they ultimately deserve.

Works Cited Advancing Medication Adherence. (2013). Retrieved November 1, 2013, from http://info.cvscaremark.com/our-company/corporate-responsibility/customers/medication-adherence Albrecht, S. (2011, May 18). The Pharmacists Role in Medication Adherence. Retrieved November 1, 2013, from http://www.uspharmacist.com/content/d/feature/i/1500/c/28121/ Bosworth, H. (2012). Medication adherence: Making the case for increased awareness. Retrieved from http://scriptyourfuture.org/wp-content/themes/cons/m/Script_Your_Future_Briefing_Paper.pdf Bosworth, H. B. (2010). Medication Adherence. Retrieved November 1, 2013, from http://link.springer.com.ezproxy.neu.edu/chapter/10.1007/978-1-4419-5866-2_4/fulltext.html Cutler, D. M., & Everett, W. (2010, April 29). Thinking Outside the Pillbox Medication Adherence as a Priority for Health Care Reform. Retrieved November 1, 2013, from http://www.nejm.org/doi/full/10.1056/NEJMp1002305 Dayer, L. (2013). Smartphone Medication Adherence Apps. Retrieved November 1, 2013, from http://www.medscape.com/viewarticle/782609_3 Hatfield, A. (2004). Medication non-compliance. Retrieved November 1, 2013, from http://www.schizophrenia.com/newsletter/997/997noncom.htm Herttua, K. (2013, May 27). Adherence to antihypertensive therapy prior to the first presentation of stroke in hypertensive adults: population-based study. Retrieved November 1, 2013, from http://eurheartj.oxfordjournals.org/content/early/2013/07/09/eurheartj.eht219.abstract Saimi, S. (2009, June 1). Effect of Medication Dosing Frequency on Adherence in Chronic Diseases. Retrieved November 1, 2013, from http://www.ajmc.com/publications/issue/2009/2009-06-vol15n6/ajmc_09junsaini_xclusiv_e22to33/1 Testman, J. (2010). Invisible Epidemic. Retrieved November 1, 2013, from http://todaysgeriatricmedicine.com/archive/050310p24.shtml