Medication nonadherence
Medication nonadherence refers to the failure of patients to take prescribed medications as directed, a significant issue affecting approximately half of all patients in the United States. Several factors contribute to this phenomenon, including fear of side effects, mistrust of healthcare providers and pharmaceutical companies, and a lack of perceived need for the medication, especially in cases where chronic illnesses do not present noticeable symptoms. Economic barriers, such as the high cost of medications, also play a critical role, often leading patients to skip doses or forgo filling prescriptions altogether.
The consequences of medication nonadherence can be severe, resulting in poor health outcomes and substantial economic costs, with estimates suggesting it contributes to around 100,000 deaths and $100 billion in preventable healthcare expenses annually. Moreover, patients with complex medication regimens or those dealing with mental health issues, like depression, are at an increased risk of nonadherence. To combat this issue, healthcare professionals advocate for improved communication between patients and providers, emphasizing the importance of patient engagement and understanding in medication management. Addressing these factors is crucial for enhancing adherence rates and ensuring better health outcomes for patients.
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Medication nonadherence
According to data published in 2023 by the American Medical Association (AMA), approximately half of all US patients fail to take prescription medications as directed. Failure to follow physician guidelines with respect to the use of prescription drugs is known as medication nonadherence.
The AMA notes many factors that contribute to medication nonadherence. Major examples include fear of negative side effects, mistrust of doctors or pharmaceutical manufacturers, and a perceived lack of apparent symptoms. Many other cultural, psychological, and personal factors influence individual patients’ decisions not to use their prescribed medication as directed.
Healthcare professionals note that medication nonadherence has major negative impacts on patient outcomes and economic costs. A 2018 study review in the peer-reviewed Permanente Journal noted that medication nonadherence is believed to be a direct contributing factor to at least one hundred thousand deaths and $100 billion in preventable healthcare system costs each year in the United States.
Background
In the United States, the Food and Drug Administration (FDA) functions as the sole body with the authority to approve a prescription medication for use in patients. The FDA uses a rigorous process for approving new medications, which unfolds across three major stages. This process begins with an FDA review of the medical condition being targeted by a proposed drug and the treatments currently available for that condition. Promising proposals then enter a multi-phase clinical testing assessment, which generates clinical data that allows FDA officials to evaluate the drug’s safety, efficacy, benefits, and potential drawbacks. Drugs that pass this clinical testing process then become subject to the FDA’s risk management guidelines, which include detailed product labeling practices and, in some cases, the development of a risk management and mitigation strategy that remains the responsibility of the drug’s manufacturer.
The FDA notes that all drugs—including familiar, widely used drugs with long and well-established safety records—carry some degree of patient risk. These risks primarily extend to the possibility of patients experiencing adverse reactions and side effects. Though most FDA-approved medications carry relatively little risk of causing serious side effects and adverse reactions, patients may have the perception that the risks they face are higher than statistical averages.
In the United States, drug companies face relatively little regulation about consumer pricing. Pharmaceutical manufacturers set prices based on factors including a drug’s efficacy, its favorability profile relative to similar medications, and competitive market forces. They are also free to impose price increases of any amount they believe the consumer market can absorb, and as such, major drugmakers enjoy immense profitability. A 2019 study conducted in the United States by the Kaiser Family Foundation (KFF) found that 80 percent of respondents believe that profit motives directly impact the drug prices set by pharmaceutical companies, while just 25 percent trust drug manufacturers to set prices at fair levels.
Some chronic illnesses, including serious and potentially fatal conditions such as heart disease, can present with few or no symptoms. Patients may therefore perceive no need to take a prescribed medication to manage such a condition, particularly if the recommended drug carries high costs or if the patient believes the drug poses an elevated risk of causing adverse reactions. When multiple such considerations influence a patient’s thinking about a particular drug, medication nonadherence becomes more likely.
Overview
The AMA cites fear, high costs, mistrust, and lack of a perceived need for a prescribed drug as leading causes of medication nonadherence. According to the AMA’s analysis, fear primarily relates to the possibility of a prescribed drug causing adverse reactions or negative side effects. The patient may have previous firsthand experience with adverse effects, either from the drug being prescribed or a similar medication. They may also have seen family members or friends experience adverse effects after using the same drug, or a similar one.
Drug costs pose a difficult obstacle for medical professionals seeking to improve adherence rates among their patients. High costs may result in a patient electing not to fill their prescription, or in the patient using the medication at lower-than-recommended frequencies or dosages to make their prescription last as long as possible. In the latter case, the patient may experience reduced benefits from the drug, or no benefits at all.
Mistrust represents another complex issue. As of 2023, the United States and New Zealand are the only two advanced economies in the world that allow drug companies to market their products directly to consumers. In the United States, many patients believe that doctors recommend or prescribe medications that may not be medically necessary to earn commissions or other financial benefits from their manufacturers. This mistrust of the US pharmaceutical industry’s consumer model frequently results in patients believing that the drug prescribed by their doctor may not be medically necessary, even when it is.
Chronic conditions, including serious and potentially life-threatening ones, sometimes display few or no perceptible symptoms. In other cases, patients may not feel any change in their body after using a prescription drug to control a chronic condition. Alternatively, a person may experience a short-term improvement in their symptoms after beginning a new drug regimen and elect to stop taking the drug because they think that they no longer need it. Researchers have associated each of these situations with increased rates of medication nonadherence.
Additional factors in medication nonadherence cited by the AMA include a failure to understand the medication, how it works, how to use it properly, and its potential benefits. Patients with complex treatment programs that involve many different medications are also at higher risk of nonadherence, as are those who harbor concerns about becoming dependent on a prescribed drug for symptom control or general health. The AMA has also found that people who suffer from depression are more likely to avoid following recommended drug usage or dosage guidelines.
Clinicians and researchers continue to debate methods for reducing rates of medication nonadherence and its associated human and economic tolls. Experts stress the importance of involving the patient in the process of prescribing drugs through dialogue and active feedback. The AMA also recommends that doctors try to prescribe drugs covered by the patient’s health insurance and shift patients on complex drug regimens to longer-acting formulations and medications that address multiple relevant health factors whenever possible.
Bibliography
“8 Reasons Patients Don’t Take Their Medications.” American Medical Association, 22 Feb. 2023, www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications. Accessed 5 Sept. 2023.
Adams, Alex J. and Samuel F. Stolpe. “Defining and Measuring Primary Medication Nonadherence: Development of a Quality Measure.” Journal of Managed Care & Specialty Pharmacy, vol. 22, no. 5, May 2016, pp. 516–523.
Bunis, Dena. “High Prescription Drug Prices Lead Many Consumers to Ignore Doctors’ Orders.” AARP, 21 Aug. 2019, www.aarp.org/politics-society/advocacy/info-2019/drug-prices-consumer-impact.html. Accessed 5 Sept. 2023.
“Development & Approval Process.” Food and Drug Administration, 8 Aug. 2022, www.fda.gov/drugs/development-approval-process-drugs. Accessed 5 Sept. 2023.
Hawley, Julia. “How Pharmaceutical Companies Price Their Drugs.” Investopedia, 30 Sept. 2022, www.investopedia.com/articles/investing/020316/how-pharmaceutical-companies-price-their-drugs.asp. Accessed 5 Sept. 2023.
Kleinsinger, Fred. “The Unmet Challenge of Medication Nonadherence.” The Permanente Journal, vol. 22, 2018, pp. 18–33.
Kodjak, Alison. “Poll: Americans Support Government Action to Curb Drug Prices.” National Public Radio, 1 Mar. 2019, www.npr.org/sections/health-shots/2019/03/01/699086303/poll-americans-support-government-action-to-curb-prescription-drug-prices. Accessed 5 Sept. 2023.
Liu, J., et. al. “Risk Factors for Self-Reported Medication Adherence in Community-Dwelling Older Patients with Multimorbidity and Polypharmacy: A Multicenter Cross-Sectional Study.” BMC Geriatrics, vol. 23, no. 75, 2023.