Map of life expectancy at birth from Global Education Project.

Wednesday, November 26, 2014

Take your @#$%^ pills!

In case you don't know what the Cochrane Collaborative is, it's an organization that compiles systematic reviews of medical interventions, conducted according to rigorous standards. There's a new one on interventions to improve medication adherence, and it isn't pretty.

A commonly bandied about round number is that about half of prescribed medication doses aren't taken. Of course the number varies according to the kind of medication and the circumstances, but there's no denying that people often don't take their pills as prescribed. Sometimes this matters a lot, sometimes a little, but even people with a lot to lose -- such as people with HIV, or glaucoma -- don't all take their medications regularly.

Well, the Cochrane reviewers looked at 182 randomized controlled trials and found only 7 high quality trials that showed any beneficial effect on medical outcomes and even those were pretty small. And the interventions were complex and expensive, pretty close to having a nurse move in with you. I've spent years trying to figure out why this is. There are a lot of different reasons but here are a few of the most important.

1) If I take the pills, that means I have the disease. And I don't want to have the disease. This would seem to reverse cause and effect but it doesn't really. There are two meanings of "having the disease": The doctor's meaning, which is a biological construct; and the patient's meaning, which is a psychosocial construct.

2) There are other things in life that are higher priorities. Swallowing pills isn't particularly hard, but constantly dealing with refills can be a hassle, co-pays matter to many people, and it's easier just to convince yourself that it isn't really necessary.

3) The person doesn't believe the doctor's theory about what's good for him or her. Not extremely common but totally dispositive when it happens. The many well-publicized instances of drug company malfeasance make this actually not entirely ridiculous. Sometimes it's even true.

4) People just don't like taking pills, they can't even say why.

Any other reasons of your own?


Daniel said...

I take the pills, morning and night. I use a 7 day morning/night pill box, and it's the only reason I remember to do this.

A Canadian relative told me of a program she volunteers in that she claims has efficacy. Volunteers like her regularly call patients that are at a high risk of stroke and talk to them about their medications etc. have you heard of this program?

Cervantes said...

Yes, I've heard of programs like that. I think they probably work for some people, if their problem really is just forgetfulness.

Hasib Rahman said...

Wonderful!! If I had to add to your already great list, it would be just to say "Make a plan". I will need to do for them. To work more efficiently, you definitely need to plan ahead.
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