Medication Adherence: It's A Problem, Unaddressed

A guest post by Dr. Anthony Sterns.

One of my great joys in life is working with people who are both brilliant and gracious. Tony Sterns, Ph.D., is one such human. He’s a deeply kind and decent person who is also very, very funny. This quality gets you through a problematic grant review, losing someone close to you, or who knows what else. Tony cares deeply about addressing avoidable suffering. The following article is lightly edited from his pen. He’s the Founder of iRxReminder and works relentlessly on the problem of medication adherence. A prior interview with him is available here.

Without further ado,

As a reminder, I have an upcoming event; I’ll plug it again at the bottom.

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Medication adherence is one of the biggest unsolved problems in medical science. You wouldn't think you would skip or stop taking your critical daily life-saving medication, but 52% of older adults and 25% of behavioral health patients do it every year. This has tremendous harm and severe consequences for personal health, healthcare systems, and our society.

First of all, non-adherence often leads to disease progression, new complications, and flare-ups of chronic conditions, from conditions like diabetes and asthma to cognitive impairments resulting from conditions like schizophrenia and bipolar disorder. It can also lead to death. There are at least 125,000 preventable medication-related deaths every year from not taking your medication correctly. To put this in perspective, in 2022, there were “only” 81,106 overdose deaths from opioids of all types, according to the CDC.

Research shows that 33 to 69% of hospital admissions are due to medication-related.  In cardiology, we know that 60% of emergency room visits are directly related to medication failures, not enough or taking too much. Historically, this is thought to cost around 300 billion annually, but more recently, that number is projected to be over 500 billion. Take a minute with that number…

$500 billion in preventable, avoidable harm to our mothers, brothers, fathers, sisters, and even children.

There's also a burden on healthcare workers. As a result of non-adherence by patients living with behavioral health challenges, healthcare workers leave at a 40% rate annually. The combination of 25% “patient disengagement” and 40% staff turnover combined leads to 33% uncollected behavioral health center revenues. We talk about how mental health is under-reimbursed, but if we aren’t collecting the money, our centers would be paid otherwise. Oh, my!

Most “adherence issues” are addressed using standard tools: the digital watch and the seven-day pill box. The first problem with these tools is that they separate all the most important medication information… from the “swallowing” of the medicines! This includes warnings and directions. The second problem is that there's no accountability; making mistakes in putting the medication in a pill box is easy. No one knows that you're taking them out correctly, either. So, these tools are responsible for the enormous costs and mortality.

There are other problems with the digital watch and virtually all “advanced alerts?” They are basically alarms. Alarms go off at the same time every day. Still, humans like to take their medications a little bit early and not exactly at the same time every day. When we set up an alarm that occurs after we've taken the medication, it is training ourselves to ignore it. So, this reinforces ignoring rather than taking. We learn the lesson well—ignore the alarm. Have you checked all your emails recently?

Another challenge with a container full of pills, plus an alarm, is that it allows control to be perceived as being in the hands of an inanimate object. Humans don't like that, and so they begin to form a negative relationship with all of their critical life-saving medication. What needs to be in place is a method that strengthens individual control and reinforces that taking the medication is a positive health choice. That would be reinforcing the correct behavior.

Our team has spent the last decade conducting research that helps to understand how to reinforce correct medication taking better. How to create and build on the insights of Giants and psychology like Bandura and Skinner. They understood how to reinforce and extinguish behaviors, lessons most working on adherence tools have ignored at their peril.

 Initially, we developed an app in a palm pilot environment that collected activity data through a questionnaire. This tool asked what you were doing at the moment a few times a day and kept track of specific times when that medication was taken. Over the years, with the emergence of the iPhone, we created more sophisticated approaches that could recognize and reinforce medication taking correctly. Our apps would include a dosing window around the time of taking so that a person could take it on time in the first half of the window and, if they were forgetting, could be reminded in the second half of the time window. As we continued to develop our understanding, we added an Internet of Things pill dispenser that directly translated the dispensing of the medication into the hand— this automated the confirmation of taking your medicine.

This had an advantage! As you get better at taking your medication, you will get fewer but more meaningful alerts. It provided the kind of behavioral focus that Bandura proved most useful. You were taking your medications at a single point of decision, and every behavior was making it more likely that behavior was repeated, mainly taking your medication daily. The pill dispenser has a further advantage that we can now tie this to the care team, and for the most critical medications, we can help patients with backup to discuss non-adherence when it occurs. There's a pretty good reason for that decision: things like uncomfortable adverse reactions, emotional narrowing that comes with strong medications, and things like erectile dysfunction.  Awareness of the non-adherence allows a conversation and corrective action to be taken. It might be that you can change the time of day. What's important is that that discussion avoids a crisis that might occur from prolonged non-taking of the medication and the opportunity for all those considerable harms we mentioned above.

For a long time, healthcare professionals have left adherence exclusively as the individual's responsibility. However, the tools we provided have been reinforcing non-adherence. Specifically, learning to ignore alarms and having temples of pills tell us what to do. These create negative attitudes about taking medications and provide very unsafe and unsupervised methods for cognitively impaired individuals, especially. Our work focuses on cognitive prosthetics. They help ensure you take your medications on time and in the right amount, reinforcing that positive health decision gently. This makes it safer the less able you are to self-manage. It also becomes a diagnostic tool when you are no longer able to safely self-manage your medications and need other interventions. 

We need to carry this standard into all prescribing and use the technology we are now wrapping around medications to create the super pills of the future—the ones you will… take.

—Anthony Sterns, Ph.D., is an Organizational Psychologist and Founder of iRxReminder, LLC.

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