BARRY BLACKWELL, M.D.
Treatment adherence: A contemporary overview A review of recent research and developing concepts in treatment adherence makes clear that, since many factors contribute to poor adherence, there is no simple recipe for routine management. Some suggestions for detecting the problem are discussed, as are three goals for obtaining improved adherencebetter patient comprehension, adequate supervision and, ultimately, the patient's independent involvement in treatment without supervision.
ABSTRACT:
The pharmacologic revolution of the last quarter century brought with it increased insights into the social and psychologic complexities involved in prescribing powerful biologic substances to people. In the I950s, the placebo response was an issue, ushered in by the need to demonstrate that the many new remedies were specific. Similarly, compliance became an issue for the 1970s, ushered in by an awareness that even effective drugs are useless when not taken. This interest in adherence to treatment is attested to by an outpouring of articles on "com pliance," "no shows," "discharge against medical advice," and "treatment dropouts." A number of factors-and notably two-contributed to the growJANUARY 1979· VOL 20· NO I
ing interest in adherence. One is that the slackening pace of new drug discovery stimulated a desire for better use of existing remedies. Then new technology created the means to discover the fate of drugs by measuring metabolites in body fluids. Paradoxically, the interest in adherence came largely from health providers other than physicians, such as pharmacists, behavioral psychologists, and public-health nurses. This fact bespeaks part of the problem-physicians have operated largely on the authoritarian, but often erroneous, assumption that their orders would be followed. The patient-rights movement and concern about informed consent have played an im-
portant part in focusing attention on the adherence problem. Public concern about the dehumanized and excessively technical practice of medicine has corresponded with increasing skepticism about simplistic biologic solutions and indiscriminate use of chemical agents. This expression of concern has been echoed from within the medical profession by Engel' in an eloquent plea for a new biopsychosocial model of medical practice that incorporates social and psychologic dimensions into the existing biologic framework. The need for a wider conceptualization of drug use that would help explain the adherence issue is reinforced by the increasing attention to long-term preventive or healthmaintenance programs. In conditions such as diabetes, hypertension, and lipid disorders, adherence is a major problem; and the attitudes, beliefs, and social predicaments of the patient exert a powerful influence on health and illness-related behaviors. Adherence is a sensitive issue. Many physicians resist or resent 27
Treatment adherence
scrutiny of the unique prerogative to prescribe, since it symbolizes the essence of their physicianship. A survey conducted by pharmacists Ascione and Raven 2 found that one fifth of the physicians in one hospital did not wish patients to be told about the drugs they were taking, and another quarter wanted the patients to be given only restricted information. Scope of the problem An attempt to determine the extent of this problem reveals that what the literature lacks in quality it makes up for in consensus. The findings suggest that about half of outpatients and a quarter of inpatients fail to take the prescribed amounts of medication.) To what extent this interferes with treatment is not clear. For example, given the wide range of metabolism that individuals display, Uhlenhuth and associates4 suggested that patients may modulate their drug intake through subtle biofeedback mechanisms that titrate efficacy against unwanted effects. CharneYS has gone further by suggesting that there is a protective balance between "prescribance" and compliance. He states: ... some sort of rough and ready natural law seems to be at work, balancing the interest of both the physician and the patient; the physician will be expected to prescribe with only approximate accuracy, and the patient will be expected to comply with only modest fidelity. Thus mankind has been able to survive bleeding, cupping, leeches, mustard plasters, turpentine stupes, and Panalba. Hulka and associates
Treatment adherence: A contemporary overview A review of recent research and developing concepts in treatment adherence makes clear that, since many factors contribute to poor adherence, there is no simple recipe for routine management. Some suggestions for detecting the problem are discussed, as are three goals for obtaining improved adherencebetter patient comprehension, adequate supervision and, ultimately, the patient's independent involvement in treatment without supervision.
ABSTRACT:
The pharmacologic revolution of the last quarter century brought with it increased insights into the social and psychologic complexities involved in prescribing powerful biologic substances to people. In the I950s, the placebo response was an issue, ushered in by the need to demonstrate that the many new remedies were specific. Similarly, compliance became an issue for the 1970s, ushered in by an awareness that even effective drugs are useless when not taken. This interest in adherence to treatment is attested to by an outpouring of articles on "com pliance," "no shows," "discharge against medical advice," and "treatment dropouts." A number of factors-and notably two-contributed to the growJANUARY 1979· VOL 20· NO I
ing interest in adherence. One is that the slackening pace of new drug discovery stimulated a desire for better use of existing remedies. Then new technology created the means to discover the fate of drugs by measuring metabolites in body fluids. Paradoxically, the interest in adherence came largely from health providers other than physicians, such as pharmacists, behavioral psychologists, and public-health nurses. This fact bespeaks part of the problem-physicians have operated largely on the authoritarian, but often erroneous, assumption that their orders would be followed. The patient-rights movement and concern about informed consent have played an im-
portant part in focusing attention on the adherence problem. Public concern about the dehumanized and excessively technical practice of medicine has corresponded with increasing skepticism about simplistic biologic solutions and indiscriminate use of chemical agents. This expression of concern has been echoed from within the medical profession by Engel' in an eloquent plea for a new biopsychosocial model of medical practice that incorporates social and psychologic dimensions into the existing biologic framework. The need for a wider conceptualization of drug use that would help explain the adherence issue is reinforced by the increasing attention to long-term preventive or healthmaintenance programs. In conditions such as diabetes, hypertension, and lipid disorders, adherence is a major problem; and the attitudes, beliefs, and social predicaments of the patient exert a powerful influence on health and illness-related behaviors. Adherence is a sensitive issue. Many physicians resist or resent 27
Treatment adherence
scrutiny of the unique prerogative to prescribe, since it symbolizes the essence of their physicianship. A survey conducted by pharmacists Ascione and Raven 2 found that one fifth of the physicians in one hospital did not wish patients to be told about the drugs they were taking, and another quarter wanted the patients to be given only restricted information. Scope of the problem An attempt to determine the extent of this problem reveals that what the literature lacks in quality it makes up for in consensus. The findings suggest that about half of outpatients and a quarter of inpatients fail to take the prescribed amounts of medication.) To what extent this interferes with treatment is not clear. For example, given the wide range of metabolism that individuals display, Uhlenhuth and associates4 suggested that patients may modulate their drug intake through subtle biofeedback mechanisms that titrate efficacy against unwanted effects. CharneYS has gone further by suggesting that there is a protective balance between "prescribance" and compliance. He states: ... some sort of rough and ready natural law seems to be at work, balancing the interest of both the physician and the patient; the physician will be expected to prescribe with only approximate accuracy, and the patient will be expected to comply with only modest fidelity. Thus mankind has been able to survive bleeding, cupping, leeches, mustard plasters, turpentine stupes, and Panalba. Hulka and associates
