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College of Pharmacy Patient noncompliance, reasons why by Chris West Public Relations Prescriptions—some patients will take them, some won't. It's as simple as that.  But a clinician's definition of noncompliance reveals the reasons and contributing factors into why patients don't take their medications and lends suggestions to the increased awareness and solutions to the problem. Dr. Alex Morton “Before the who, why and when of noncompliance, you have to address the what,” said Alex Morton, Pharm. D. “Noncompliance is not just a patient's refusal to take a medication. Taking a medicine late, sporadically or in any way other than what has been prescribed is a degree of noncompliance.” Morton is talking about the world of thirds that is noncompliance. Meaning one third of patients will be satisfactorily compliant, another third will not be compliant at all and the last third will fall somewhere in the middle. “There is no singular reason behind why a patient will not take their medication, Morton said.  “Often there are multiple reasons behind it that are personal to each patient.” Side Effects While there is no pecking order to noncompliance, side effects associated with medicines top the list of reasons. “All medications have some side effect(s) attached to them,” Morton said. “The trick is to find out whether the patient feels they are worth putting up with.”  Side effects may raise other medical conditions that were not present before, they may also put patients at risk of other conditions. It is all dependent on the medication and the patient taking it. But, there are three areas that are almost universal in guaranteeing noncompliance: sex, negative effects to a person's physical features and weight gain. “If a medication decreases sexual desire or performance, causes a person's face to break out with acne or adds weight, you can count on the fact that they will not be compliant with their prescription,” Morton said. “Those are the three untouchables. But what patient's need to be told and made to understand is that side effects are treatable too and/or may not affect them at all.” Another factor linked to side effects and overall compliance is the duration of treatment. If ill effects of medicine do exist, there is a greater chance that a patient will not take it if the duration of their treatment is long. And even if no side effects are present, people on medication don't want to hear that they will be taking it for the rest of their lives. Patient Practitioner Communication “Another key factor in assuring compliance is the relationship between patient and practitioner,” said Morton. “If a diagnosis or medication is not properly explained to a patient or if the patient is met with a lack of interest and involvement, they may decide for themselves that their health isn't important to the practitioner and that they don't need their medicine, rather than ask questions regarding it. Good communication and education are paramount.” Dr. Morton, right, addresses a patient on prescription compliance. People also have their own personal attitudes about medicine. Many associate a medicine with the fact that “There is something wrong with me.” Taking a pill every day reminds some that they are sick or some may have asymptomatic conditions and assume they are don't need their medication. “To some people, a drug is a drug is a drug,” Morton said. “There are many feelings and attitudes that arise in people when you start talking about medication. Some people are in denial about their illness. If they don't take their medicine, they must not be sick. To others there is a fear of dependency, whether that risk exists or not. And to other patients, if they have no visible symptoms or don’t ‘feel sick,’ then taking the medicine becomes an option.” People who are sick also want the quick cure that will rectify their situation and return them to their everyday lives. This is where expectations fuel noncompliance.  “A patient's expectations of their medicine is also a key factor in compliance. What many patients don’t understand is that medicine isn't always about ‘a cure.’ Often it is about improvement and prevention.” There also exists a connotation that many people assign to medicine. Some people base their opinions on medicine around what they hear. “A patient may come to see me and have an anxiety disorder,” Morton said. “And when I recommend an antidepressant, they don't understand, often saying: ‘But I'm not depressed,’ all the while not realizing its benefits to their anxiety.” Obvious other factors that contribute to noncompliance are cost, understanding of prescriptions and medications and a large drug regimen. “The cost of medication is and will always be a contributing factor to noncompliance,” Morton said. “With inflation around research, the prices of some medication are very expensive.” “The patient's understanding of the medication prescribed is important in that other factors may exist that contribute to noncompliance. If an adult patient with a literacy deficit, an extremely touchy and potentially embarrassing condition, isn't properly told how to take his/her medication, the literacy problem won’t likely be addressed and chances are they won't take their medicine as directed or at all.” Complex Drug Regimen “And finally, in patients with a pre-existing complex drug regimen, it becomes difficult to keep up with so many different medications. That results in forgetting to take the proper medication at the proper time, taking the right medicine at the wrong time or forgetting to take it all together.” Morton says solutions to the problem lie in education and communication between the patient and practitioner and patient and pharmacist. “Interacting with the patient about their condition and medication, being straightforward about the duration of treatment and potential side effects regarding treatment; encouraging questions and concerns and follow-up visits with patients regarding their progress are all sufficient in reducing noncompliance and increasing the odds of recovery and improvement.” Morton is also sure to bring those solutions to the upcoming doctors he teaches. “Our faculty in the College of Pharmacy frequently discusses the issues surrounding noncompliance in our classes and patient practice sites,” Morton admitted. “This is important in raising awareness of this problem with all health professions programs on the MUSC campus.”   Docs inform patients, parents through recent publication A year and a half-long benchmark collaboration between two Institute of Psychiatry (IOP) doctors has produced a comprehensive new book regarding Ritalin and its part in treatment of Attention Deficit Hyperactivity Disorder (ADHD). Pharm.Ds. John Markowitz and Lindsay DeVane,  co-authored the book, “The Ritalin Handbook: What Every Parent and Patient Should Know,” as a lay guide to Ritalin and several topics that surround it. “We noticed that within an ocean of literature regarding ADHD the disorder, there was a lack of information regarding its treatment,” Markowitz said. “The handbook is an effort to inform and answer questions that parents and patients might have in reference to the medicine that they won’t find on a small Ritalin pamphlet.” The handbook introduces the reader to ADHD, but remains predominantly exclusive to topics surrounding Ritalin. This rounds the book out as a field guide to parents/patients, but also makes it valuable to health care practitioners.  “Where it was written as a reference book for the average person, its value to health care professionals comes from the fact that it is very comprehensive,” Markowitz said. “It is referenced to other research, books and studies, gives an in-depth look at the make-up of the medicine and contains some of the independent research that Dr. DeVane and I have done in the IOP.” Included is a chapter addressing the recent controversy surrounding the increased diagnosis of ADHD in children and adults. “We’ve included a chapter that does touch upon the recent increase in ADHD diagnoses and the controversy attached to it,” Markowitz said. “But I attribute most of that controversy to an increased awareness of the illness among healthcare practitioners, so it is being looked for more often. And it is being found that there are high rates of ADHD in children and adults now more than ever.” The book also contains a chapter on frequently asked questions regarding Ritalin and ADHD and a glossary of terms used throughout the book. “With the increase in psychostim-ulant prescriptions to children, and with the highest percentages of those being Ritalin, we felt a simple, yet informative, guide to its most dominant treatment was pertinent.” To obtain a copy call 1-800-253-9104 or log on to its Web site at <http://www.amazon.com>.