The People's Perspective on Medicine

The BIG Business of Getting You to Take Your Pills

Health professionals have a terms for "good" patients. They are "compliant." Do you take your pills? If so, you are compliant. Reminders are big business!
Two hands holding a variety of pills supplements

Who cares if you take your medicine? A lot more people than you might think. Let’s start with drug companies. The more pills they sell, the bigger their profits. Pharmacies want you to take your pills for the same reason. They are constantly reminding you that your prescription is ready for pickup.

“Compliance” or “Adherence”?

There has been an amazing amount of research devoted to getting people like you to take your pills. Pharmacists and physicians have been trying to discover strategies to get people to take their medicines as prescribed. The old term was medication “compliance.”

That has fallen into disfavor because it sounds a little too patronizing. Remember what it felt like when a parent reminded you to “eat all your vegetables.” Or perhaps you were chastised by a teacher for not completing your homework on time.

These days, experts like to refer to medication “adherence.” This implies that the patient is using his or her medicine regularly as directed. It seems a bit more friendly than compliance, but the meaning is the same. 

Why You Should “Take Your Pills”

There are certainly many situations where it is essential for patients to take their medications. People with HIV, for example, need to be rigorous about controlling the virus that could get out of control. As a result they must be very conscientious about following their medication regimen.

Cancer patients are often given a cocktail of toxic drugs. Completing the course of treatment can be challenging, but following the program may make a durable remission more likely.

People with tuberculosis must also take all their medicine for at least four months. Otherwise, this stubborn infection could persist and infect others.

There are many other situations that require you to take your pills conscientiously. These are just some examples.

Why Pharmacies Bug You To Take Your Pills:

Not surprisingly, pharmacies and the pharmaceutical industry are very interested in the concepts of compliance and adherence. The more pills people take, the more money these industries make.

If that sounds cynical, consider the estimate that the pharmaceutical industry loses over $200 billion annually because people don’t fill or renew their prescriptions. That may be conservative. Here is an estimate from the PRNewswire (Nov. 16, 2016) a few years ago: 

“HealthPrize Technologies today announced the publication of an update to a research paper co-authored with Capgemini estimating annual pharmaceutical revenue losses of $637 billion due to medication nonadherence to medications for the treatment of chronic conditions. Globally, revenue loss has increased from $564 billion in 2012 to $637 billion in 2015, with US-based revenue losses increasing from $188 billion in 2012 to $250 billion in 2015.”

The Business of Adherence:

An entire business has evolved to encourage people to keep taking their medicines.

Research:

First, there is research to convince prescribers that the more pills people take the healthier they will be. Such studies can be expensive to conduct.

There are over 30,000 published reports in the medical literature about adherence and compliance. A key message is that people who skip medications risk developing complications that require hospitalization (Risk Management and Healthcare Policy, online, Feb. 20, 2014).  Doctors, pharmacists, nurses and other allied health professionals are enlisted to encourage patients to take their medicine.

Reminders:

Second, there are organizations devoted to reminding people to take their medicine. Automated refill reminders have become standard in many pharmacy chains.

People get phone calls, text messages and emails reminding them to pick up their prescriptions. If those strategies don’t work, an actual person may call you up and encourage you to renew your prescription or take your pills as directed.

Cost:

Third, cost can be an issue. Many medications are pricey. Pharmaceutical companies have come up with strategies to make this less onerous for the patient. They offer “copay cards,” “access cards,” “coupons” and “discount cards” to reduce the amount a patient has to pay out of pocket.

Such coupons may seem like a great deal for patients, but it is also a way to get patients on board the pharmaceutical train. Once the insurance company agrees to pay, the drug manufacturer can collect big bucks indefinitely. Here is how MarketWatch (Jan. 3, 2017) describes “The real reason drug makers offer discount cards (you’ll pay eventually).” 

“But recent research has bolstered critics’ claims that these coupons only serve manufacturers’ interests, pushing patients away from cheaper alternatives and costing the broader health-care system billions of dollars in the process.

“’At the end of the day, the consumer is always paying for it, in some form or fashion,’ said Michael Rea, the founder and chief executive officer of Rx Savings Solutions, a software company that works with employers and health plans to help patients comparison shop. ‘They may think they’re getting a really good deal, but in reality it’s costing them more money.’”

“’The more that patients use drug coupons to obtain brand-name medications when lower-cost alternatives are available, the more expenses will rise for their insurers,’ making insurers likelier to raise their rates, said the NEJM piece [New England Journal of Medicine, October 2, 2013].’” The NEJM article was titled:

“Prescription-Drug Coupons — No Such Thing as a Free Lunch”

Side Effects:

Fourth, side effects! Many of the articles about noncompliance or nonadherence do not like to mention the elephant in the room: adverse drug reactions. Many people ignore the advice to “take your pills” because of drug side effects. If a statin makes your muscles hurt so that you can no longer exercise, you might question the value of the drug. If gabapentin for pain or insomnia causes brain fog you might not want to keep taking it. Learn more at this link:

Can Your Medicine Cause Confusion or Memory Loss?

What About Lifestyle Changes?

Compared to the amount of money and attention devoted to adherence, prevention gets short shrift. The pharmaceutical industry, which underwrites a huge amount of health care research, has no vested interest in promoting lifestyle changes that could reduce the burden of disease and the number of pills people have to take.

Instead of tens of thousands of research reports, health coaching and lifestyle management have garnered only a few hundred published studies.

Doctors Get Frustrated! 

Doctors often express frustration that they tell their patients to stop smoking, lose weight, exercise regularly and eat more vegetables and fruits. But at the next visit nothing has changed. Many patients have not made the recommended changes.

These behaviors could have a profound influence on overall health and reduce the need for many medications. Blood pressure, blood sugar and cholesterol all respond well to such interventions. But changing behavior is really hard. Scolding doesn’t help people change entrenched habits. Health coaching could make a difference, though (Work, May 24, 2019). 

What is Health Coaching?

According to Wikipedia

“Health coaching is the use of evidence-based skillful conversation, clinical interventions and strategies to actively and safely engage client/patients in health behavior change. Health coaches are certified or credentialed to safely guide clients and patients who may have chronic conditions or those at moderate to high risk for chronic conditions.”

Lifestyle interventions can be effective even for challenging conditions like obesity (PLOS One, April 18, 2018).  In addition, people who make healthy lifestyle changes may be able to reduce or discontinue medications for hypertension, high cholesterol or diabetes under their doctors’ supervision.

Healthcare providers are rarely trained in health coaching, however. They don’t have the time or the staff that can help deliver these interventions and follow up with patients. Moreover, insurance companies are accustomed to reimbursing for procedures and prescriptions, but not for coaching.

Perhaps the pervasiveness of drug advertising is more harmful than we imagine. Rather than promoting a pill for every ill, we should be helping people prevent health problems in the first place with diet, exercise and other helpful lifestyle strategies.

What Do You Think?

Have you ever been reminded to take your pills? Do you get messages from your pharmacy to pick up your prescription(s)? Share your thoughts on the issues of compliance/adherence in the comment section.

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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    I’m tired of getting text msgs that say my 90-day prescriptions are due for refill, only 30 days after I last picked them up! Or the msgs that urge me to sign up for auto refills. My late husband had auto refill. Pretty soon, he had more than a year’s supply of his meds piled up, and they kept coming after he died, even after the mail-away pharmacy was notified of his death. They said they couldn’t stop meds already “in the pipeline” nor could I refuse to pay for the unwanted shipments or return them, due to HIPPA laws!

    I learned that lesson well, and will never voluntarily enroll in auto refills! Even the insurance companies push auto refills and 90 day mail-away scripts. But if your doctors change your meds, you are stuck paying for meds you can’t use, return, or even give away due to consumer unfriendly laws, that support Big Pharma at the expense of the patient!

    Adherence is needed for vital drugs. Some of the vital drugs like BP medications, sleep, antibiotics, etc. are inexpensive. Others like the ones for arthritis, diabetes, etc. are much needed and covered by insurance. We cannot blame pharma companies for these drugs. However, TV advertising of expensive drugs is not right.

    I have been dismissed from 2 doctor’s practices for being non-compliant. The last doc wanted me to take a statin. I made some lifestyle changes (supplements/exercise), and when I saw her next my cholesterol had dropped 40 points. She asked how I was doing with my statin, and I told her I never filled the script. I lowered my chol. on my own. She became enraged and shouted “No, no! That won’t work, you must take the meds”. What??

    I was badgered the other day by my PCP to take Repatha for my high LDL cholesterol. He asks every appointment if I want to try it and I say, I don’t trust the side effects that I’ve read about Repatha. This time, he was relentless; he went on and on and on. He pretty much was bullying me. Then he asked me why I even come to him if I won’t accept aggressive treatment. I said because the pharmacy won’t just give me the RX’s I need to take.

    Also, the pharmacy does text me every day, if I haven’t picked up a med or if I want a med refilled.

    I have literally been badgered, yelled at, and kicked out of a hospital because doctors at the hospital have tried to get me to take pills for lowering blood my blood pressure for THE REST OF MY LIFE!, even though my normal blood pressure is usually 122 over 78.

    One doctor told me “I don’t care what your blood pressure is normally.” I am in the hospital because I have a virus and my blood pressure is raised – doesn’t anyone who is sick enough to be hospitalized suffering from elevated blood pressure? How many thousands of people being prescribed blood pressure medicine needlessly? This practice needs to be stopped NOW. Lenora S

    my PCP once noted in my chart that i was “non-compliant” when i refused to fill his scrip for a statin, and on another occasion i insisted on a my old scrip for Losartan when he re-wrote it for the HCT version.
    i’m still here, and he’s not

    I receive one reminder from Walgreens when a 3-month prescription is due to be renewed. This does not bother me. In fact, it’s nice to have the heads up, since one might not have kept track and realized that the 3 months is nearing its conclusion.

    I do not have automatic refills on any prescription. My mother, however, does on one of hers, which she also receives on a 3-month basis. Her pharmacy calls to notify her when it is ready to be picked up.

    It’s always about the money. I am allergic to many drugs and refuse to take others. My husband takes any pill that is handed to him and we disagree a lot about his willingness to be “compliant”.
    That word is not in my vocabulary. I learn as much as I can about the side effects of drugs and then decide whether or not I want to risk it.

    I was hospitalized for five days with a serious infection when I was taking warfarin. New infections continued for several weeks after I got out of the hospital, and my GP doc had to prescribe a variety of anti-biotics as different infections would arise. In addition, I was becoming resistant to the antibiotics, and my GP doc was running out of anti-biotics to prescribe.

    I stopped taking warfarin and surprise, surprise, surprise, the infections stopped and went away. This was over two years ago, and I cannot take any of the other blood thinners as I experience terrible side affects with those also. My then cardiologist became very upset with me when I refused to take any blood thinners. I changed cardiologists.

    Last week I had a minor facial surgery, and the dermatologist had difficulty with excessive bleeding, and I am not on any blood thinners. Could it be that life style has something to do with that? My diet is totally plant-based, and I eat at least one recipe of Asian food daily containing turmeric, garlic, curry, and ginger root.

    Thanks for this very thorough article. I’m an RN and do find it necessary to take multiple medications for conditions which are congenital and which are only slightly improved by long time life style efforts.

    Several of these meds are very expensive, even after insurance coverage (also very expensive!). But I’m “compliant” – they help me function, perform routine daily tasks, and experience less physical distress.

    Two examples of reminders and incentives I receive:

    1. Rite Aid emails me consistently to remind me to refill my prescriptions. Once I order the refill, I get more emails advising me to not forget to pick them up.

    2. Boeringer-Ingelheim manufactures several inhaled medications to improve breathing–I take one of them. They have a “coupon” that covers my copay, which is steep. I also signed up for their Respipoints program: I get daily emails reminding me to use the inhaler, and they have several mini-tasks offered up (surveys and quizzes). Participating in this program rewards me with points I convert into gift cards.

    I do have difficulty seeing how pHarma’s push to get people to take their meds “as directed” is harmful in the short term. As for long term: the economics, ethics, and liabilities of this discussion are much too intricate for me to wrap my head around!

    Thanks for a great article. At 79, I take a beta blocker twice a day for keeping my blood pressure at a good reading, and that is the only pharmaceutical I take. It’s been hard work for a woman who is sensitive to begin with to have these conversations with doctors, but I suggest readers do their own research, and then make decisions that seem sensible. You will sometimes find doctors who agree with you but are caught in health care/insurance systems’ requirements. Ugh.

    It is very frustrating when pharmacies keep calling, texting, emailing etc about renewals. I had to call the ‘head quarters’ of one such organization to get them to stop. It was not for drugs i needed to take long term and i was confused when they wanted me to continue – until i realized it wasn’t about me it was about the $$$$$.

    J

    Once I got a message to pick up my pills without ordering them! I do have a reminder set up, but it’s not automatic refill. Plus it happened when I was switching insurance and the possibility of being refunded $1200 for the premium was based on not using the insurance that month. I was furious!

    While you mention the concern many folks have about side effects, and that drug companies like to claim pills can prevent complications, another fact is that research has shown a yearly average of about 120,000 deaths from prescription medications – not to mention hospitalizations. These are dangerous chemicals to be used with very knowledgeable care. And yes we have been called by our CVS pharmacy to remind us to renew a Humulin N prescription (cost $150) after 30 days. But our dog only needed 4 units BID, and my investigation showed me that it is NOT out dated until the date posted on the vial. It lasted 3 months. Then we got Novolin N at Walmart for $25. Eli Lilly is pretty greedy.

    My husband and I were just talking about “health coaching,” and our frustration that treatment has become such a big business. Our clinic/hospital just did some major upgrades to both facilities, and I’m betting a lot of that is to attract more business. In fact it seems like a lot of the new construction in recent years has been for new clinics. It’s amazing to see how much this industry has grown. Not only that, they’re busy!

    Over the past several years I have been directed, instructed, importuned to take statins, proton pump inhibitors, anticoagulants, and beta blockers, sine die. I refused the statins up front, took the PPIs until my ulcers healed, took the anticoagulant until I learned it was an anticoagulant, and took the beta blocker for one day. I stopped that when I found myself unable to correct a grocery store clerk who had undercharged me.

    At this time I take nothing. This amazes treaters, but come one. If I had been taking all they wanted me to take I’d be dead.

    Sometimes, though, I think that’s what they want. I’m collecting on my years paying into Social Security. There are people in the system that don’t like that. They want people like me out of the system and pharmaceuticals will do that. I view pharmaceuticals the way I view high fructose corn syrup (HFCS-55). They’re poison but slow-acting, so when the end comes, it can’t be attributed to them. Short term they’re fine (except for HFCS-55, which is never fine). Longer term they’re killers, disablers, agents of physical distress and mental impairment. Please. Aging is tough enough already.

    CVS has become insufferable regarding phone calls, filling prescriptions for drugs that we did not order to be refilled, and then calling and pestering us to come pick them up.

    For instance, I take warfarin. I know I have to take it regularly. The physician prescribes 145 pills for each 90-day refill, because the Rx can vary with the INR results. Because I take 7 1/2 pills every week, the prescription is not ready to be refilled every 90 days. That does not stop CVS, they refill it, and once I gave in and picked up the new bottle even though I did not yet need it. But the next time they started pestering me, I had 82 pills left. So they called and called and called and called and called, trying to get me to pick it up.

    They need to mind their own business and stop trying to be my mommy and my daddy, and let me do what I have always done, that is, decide when to call for a refill. Sometimes with other drugs, the doctor tells me to modify the dose, take less, so the same thing happens. Again, CVS, butt out, when I am ready for a refill, I will call you. Oops! That was the way it used to be.

    CVS has installed the most obnoxious, idiotic, robotic system on the phone, that I do not want to call CVS, ever again. I guess I will have to switch to another pharmacy. CVS does not want to be merely a retail pharmacy, but get real, CVS. That is exactly what you are, and you have transformed your self into a rather poorly performing one.

    Forgot to mention, they switched their phone some time ago, before the idiot talking robot came on the scene, to a poorly calibrated digital mess, that begins robo messages when our phone picks up, rather than waiting until our message ends. That means that the message they leave us is useless, in that it starts in the middle or near the end, we do not know which one of us it is for, and it is obnoxious. They tell us to call them. This is a sucking effect on my time and energy, but before the talking robot, I used to do it. Now, I want nothing further to do with CVS. Or any other pharmacy that has such contempt for its customers.

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