College of Public Health students graduating

America, it’s time for us to take our medicine.

The New York Times recently reported on what they call “an out-of-control epidemic” of nonadherence to prescription drug regimens in the US. Citing a 2012 paper from the Annals of Internal Medicine, the Times claims that “… 20 percent to 30 percent of medication prescriptions are never filled, and…approximately 50 percent of medications for chronic disease are not taken as prescribed.” A 2014 study found that those who do fill prescriptions only take about half the recommended doses.

Why are so many Americans not taking prescription drugs as directed? And how can public health professionals help?

Medication adherence is critical to improving health. Some of the most common chronic health conditions in the US – hypertension, high cholesterol, and diabetes to name a few – respond well to prescription medication.  Yet adherence to long-term regimens for these conditions is poor. Alarmingly, studies have shown that patients with transplants, heart attacks, and asthma don’t take medication regularly either.

Cost is one obvious barrier. Fortunately, common drugs like statins are relatively affordable.  Even most SSRIs, the first line of medication therapy for depression and anxiety, are available in low-cost generics. Nonetheless, the populations most likely to need these drugs are also most likely to be poor and/or elderly. Even $24 for a three-month supply of generic medication can break their budgets. And getting to the pharmacy without a car is a challenge in rural areas. Patients report cutting pills in half or taking them every other day to stretch their supplies.

A general aversion to medication is another factor in poor adherence. Medication is associated with illness, so some may believe that taking medication will confirm that they are ill (whereas not taking medication allows them to believe they are well). This aversion turns up often in rural cultures focused on rugged individuality and self-reliance.

A reliance on holistic or homeopathic remedies is another factor in medication avoidance. Essential oils smell wonderful, but evidence-based medicine does not support using them in place of FDA-cleared medications.

Public health workers have a variety of roles to play in increasing medication adherence.

When it comes to cost, patient navigators and caseworkers can assist patients in signing up for a variety of savings and insurance programs. Pharmacists can recommend lower-cost alternative therapies. As the health insurance landscape continues to change, social workers and clinical staff will also be critical in helping patients find solutions to high drug costs.

The flip side of a culture focused on self-reliance is the importance of faith community and family relationships. This is evident in the close networks of people in rural Appalachia, for example. Public health advocates who are long-time community members play a significant role in supporting and checking on patients and their progress. From local health department staff, to peers at work, to faith leaders, members of a patient’s network can encourage them to adhere to medications as prescribed.

Finally, clinicians and their staff must be cognizant that it’s not enough to simply prescribe a medication – they must educate patients about its benefits. In an era of people who “play doctor” on the internet, it’s important to talk to patients in a comprehensive way about how their medication works, why it’s the right choice for their condition, and why adherence matters. If clinicians are too pressed for time to explain this, there is a need for community public health educators to fill the gap.

Have you ever known someone who did not take prescribed medication?
Have you done it? (Be honest.) Why?