Research consistently finds that patient adherence with prescribed medication regimens for the treatment of chronic medical conditions is frequently problematic. So, it should be no surprise that nonadherence also may be the norm rather than the exception when it comes to medications prescribed for chronic pain. According to a new study, more than 8-of-10 patients prescribed analgesics of any type for chronic noncancer pain may not always follow instructions for safe and effective use. However, this is not to say that patients should be left to suffer with pain rather than appropriately prescribing analgesics, including opioids.
Mediocre Medication Adherence Overall
A newly reported first-of-its-kind survey — Medication Adherence in America: A National Report Card — notes that adults in the United States aged 40 and older who have a chronic medical condition earn only an average grade of ‘C+’ when it comes to proper and safe medication use. Nearly 1 in 7 members of this group (15%) receive an ‘F’ when it comes to taking their medications as prescribed, and less than a quarter (24%) merit an ‘A’ for being completely adherent.
The survey — commissioned by the National Community Pharmacists Association (NCPA) — was conducted among a national sample of 1,020 adults. Demographically, the population was representative of 30% of all U.S. adults, with a median age of 60 and taking an average of 4 ongoing prescribed medications.
The report card calculated grades based on answers to 9 questions regarding nonadherent behaviors during the past 12 months, assessing whether 1) patients had failed to fill a prescription, 2) neglected to have a prescription refilled, 3) missed a dose, 4) took a lower dose than prescribed, 5) took a higher dose than prescribed, 6) stopped a prescription early, 7) took an old or leftover medication for a new problem without consulting a doctor, 8) took someone else’s medicine, or 9) forgot whether they had taken a medication. The more affirmative responses, the lower the grade.
The most commonly mentioned reason for not following prescribers’ orders was simply forgetting, cited by more than 4-in-10 respondents. Other top reasons for nonadherence included running out of medication, being away from home, affordability of medications or trying to save money, and experiencing medication side effects. Additional influences on nonadherence included the presence or absence of a personal connection with a pharmacist or pharmacy staff, a belief in the importance of following instructions in taking medications, and patients’ general levels of health information.
Pain Medication Nonadherence Extensive
Looking more specifically at pain medications prescribed for older patients, research recently reported in the journal of Pain Medicine found high rates of nonadherence with analgesic regimens. This cross-sectional study utilized a self-administered questionnaire among 100 patients aged ≥65 years being treated for chronic noncancer pain at the Health Care Centre Mostar, Bosnia and Herzegovina [Markotic et al. 2013].
The patients reported a somewhat high average pain intensity of 6.6 ± 2.2 on a 10-point visual analog scale. On average, they had been prescribed about 2 analgesics, including opioids, NSAIDs, and/or atypical analgesics. A majority (n=69) also were taking medications for comorbidities (eg, renal, cardiovascular, endocrine, GI conditions). Alternative medications for pain were used by 38% of patients, including various herbal and “natural” products.
According to their own statements, more than half of the patients (57%) were clearly nonadherent, while 84% exhibited some degree of nonadherence on the Morisky Medication Adherence Scale (MMAS-4). This instrument consists of the following 4 questions: A) “Do you ever forget to take your medicine?” B) “Are you careless at times when taking your medicines?” C) “When you feel better, do you sometimes stop taking your medications?” and D) “Sometimes if you feel worse when you take your medicine, do you stop taking it?” Slightly more than 4-in-10 patients exhibited very low levels of adherence, answering affirmatively to 3 of the 4 questions.
Nonsteroidal anti-inflammatory drugs were the most frequently taken medications, and nonadherence was more common when multiple medications were prescribed. The most common deviation from the prescribed therapy was self-adjustment of the dose and frequency of drug taking based on the severity of pain, and the second most common deviation was underuse of the prescribed analgesics. Nonadherence also was associated with patient attitudes about addiction to analgesics; half of the participants believed that one can easily become addicted to pain medications.
The researchers conclude that the high level of ongoing pain intensity and medication nonadherence found in this study suggest that physicians should monitor older patients with chronic nonmalignant pain more closely. They also should pay more attention to patients’ attitudes and beliefs regarding analgesics to ensure better medication adherence.
As former U.S. Surgeon General C. Everett Koop, MD once stated: “Drugs don’t work in patients who don’t take them.” And, the preferred term to describe the extent to which patients faithfully do take medications as prescribed by their healthcare providers is adherence.
Adherence has been defined as the “active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result” [Ho et al. 2009]. This implies that patients have a choice, and that both patients and providers mutually establish treatment goals and the medical regimen.
“Adherence” is preferred over “compliance,” because it denotes more of a collaborative relationship between providers and patients. Although, just to confuse matters, adherence is sometimes used in reference to filling new prescriptions or refilling current prescriptions on time, and compliance is the act of taking medication on schedule in the dose prescribed. Other terms, like “concordance” and “persistence,” also may describe medication-taking behaviors that are consistent with the prescribers’ directions.
The NCPA survey described above merely confirms what has already been noted in the medical literature; that is, medication nonadherence to treatment regimens prescribed for any chronic condition is a serious public health problem. Some time ago it was noted that, even among the best of patients, adherence to prescribed medication regimes typically ranges only between 30% to 50% [McLellan et al. 2000].
Schonwald  observed that rates of nonadherence to any medication range from 15% to 93%, even when there can be severe consequences. Indeed, a recent research report noted that nearly half of patients (48%) on average may not be adherent with taking life-sustaining drugs for heart failure [Zhang et al. 2013]; adherence rates ranged from 36% to only 71% at the highest.
Therefore, it is unsurprising that Markotic et al. , in the second study described above, found that up to 84% of patients were nonadherent to some extent with analgesic regimens prescribed for chronic noncancer pain. Similarly, a prior literature review, by van den Bemt et al. , found that adherence rates to prescribed regimes for treating rheumatoid arthritis were generally low, ranging from 30% to 80% at most, and this had a negative impact on therapeutic success.
As all healthcare providers know, some degree of patient nonadherence with prescribed medical regimens is a fact of clinical practice. However, when it comes to potent medications prescribed for pain, this problem can lead to therapeutic failure at best and life-threatening adverse events at worst.
Nonadherence might be conceptualized as one of two subtypes [van den Bemt et al. 2012]: A) Unintentional — due to forgetfulness or inability to follow a complex regimen, or B) Intentional — based on a patient’s decision to not take a medication or to take more or less of it than prescribed.
One observational study found that nearly half (48%) of patients were nonadherent with their opioid analgesic regimens, with 14% admitting to overusing and 34% underusing the prescribed opioid medications [Broekmans et al. 2010, also see UPDATE here]. Either over- or underuse might be considered as “medical misuse,” which could undermine effective therapy and lead to severe problems of concern.
Still, distinctions need to be made regarding patient motivation. Most important, the research on analgesic nonadherence in patients with chronic pain suggests that the vast majority of cases do not involve abuse or malevolence; that is, diversion or use primarily for desired psychotropic effects. As the studies by Markotic et al.  and Broekmans et al.  found, a common occurrence is patients self-adjusting their analgesics based on pain severity, with underuse more common than overuse of analgesics. Furthermore, economics may play a role — particularly in elderly or underinsured populations — if patients cannot afford their prescribed analgesics and do not fill prescriptions or use less to make the drugs last longer.
The NCPA survey report concludes that healthcare providers have a vital role to play by stressing the importance of taking medications as prescribed, by appropriately monitoring and helping patients to avoid or reduce unpleasant side effects that may compromise adherence, and by helping to keep patients more generally well-informed about their health conditions. Additionally, healthcare providers, including pharmacists, can help reduce nonadherence by assisting economically vulnerable patients in finding the most affordable medication options.
> Broekmans S, Dobbels F, Milisen K, et al. Pharmacologic pain treatment in a multidisciplinary pain center: Do patients adhere to the prescription of the physician? Clin J Pain. 2010;26:81–86.
> Ho PM, Bryson CL, Rumsfeld JS. Medication Adherence: Its Importance in Cardiovascular Outcomes. Circulation. 2009;119:3028-3035 [article here].
>Markotic F, Cerni Obrdalj E, Zalihic A, et al. Adherence to Pharmacological Treatment of Chronic Nonmalignant Pain in Individuals Aged 65 and Older. Pain Medicine. 2013;14: 247–256 [abstract here].
> McClellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness. JAMA. 2000;284(13):1689-1695.
> Schonwald G. What is the Role of Urine Drug Testing (UDT) in the Management of Chronic Non-Cancer Pain with Opioids? Pain Med. 2012(Jul);13(7):853-856 [abstract].
> van den Bemt BJF, Zwikker HE, van den Ende CHM. Medication Adherence in Patients With Rheumatoid Arthritis: A Critical Appraisal of the Existing Literature. Expert Rev Clin Immunol. 2012;8(4):337-351 [available here].
> Zhang Y, Wu SH, Fendrick AM, Baicker K. Variation in Medication Adherence in Heart Failure. JAMA Intern Med. 2013;173(6):468-469.
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