Prescribing Is Only the Beginning

This post was written by Michael W. Hess, MPH, RRT, RPFT

In 2016, I underwent a sleeve gastrectomy. Since then, while my health has significantly improved, I still am obligated to take various vitamins, supplements, and a few prescription meds to counter the effects of decades of obesity (as well as the side effects of the procedure itself). I know what they all do. I know how they work. I know when and how to take them. I am ostensibly the most likely patient in the world to stick with my regimen.

I usually forget.

I have tried pill sorters, phone alarms, the whole gamut of reminder tools to keep me on track. Sometimes they even work for weeks or months at a time. But, more often than not, I eventually fall off the adherence wagon and forget a dose (or two). However, there IS one medication I do take very consistently. Every single day, I take my allergy medications. I started thinking about why that might be, and a very simple answer occurred to me: I take them because I can feel it when they work. Or, perhaps more accurately, I sure feel it when I DON’T take them.

This is also true for many of the inhaled medications we administer to people with COPD. I cannot tell you how many times I have told someone, “You may have to wait a week or two to feel this controller medication working, and even then, it won’t be like a switch being flipped.” And so, I had many people report to me that it was difficult to get into the habit of taking those controllers, but they took their albuterol just as prescribed. Like my allergy pills, they could feel when the albuterol was not there.

Adherence is unsurprisingly a major issue in COPD and similar lung conditions. A recent retrospective study of people with COPD prescribed triple therapy using two inhalers (a fairly common scenario) found that only 14% stuck with their plan for a full 12 months.¹ This supports an earlier finding by the Centers for Disease Control and Prevention (CDC) that one in five of the nearly 4 billion prescriptions written in the United States every year goes unfilled, and only about half of the remainder are taken correctly.² The reasons are manifold, but there are just as many ways that you can help support the people you prescribe for.

What is adherence?

The concept of adherence is hardly controversial, but there is a fair bit of debate about how it should be formally defined for research. In the above triple therapy study, cases where at least 80% of prescription days were covered were considered adherent.¹ Broadly, adherence can actually be broken down into three phases: initiation, implementation, and persistence.³ Each phase contains potential barriers, including some unique to COPD. This is how I worked to overcome those barriers in my practice.

Initiation

The first phase is quite simply the decision to pick up the prescription. This is where the clinical “sales pitch” is critical, as many people with COPD are already on multiple medications not just for breathing but concurrent conditions.⁴ Convincing them to add one more to their home pharmacy can be a tall order. Be sure to thoroughly present the potential benefits of this new therapy in practical terms. For example, avoid stating dry objectives like, “this will improve your FEV1” and instead discuss how they may end up being able to walk farther without using a short-acting inhaler. Be sure to also consider how much this new medication will cost; some electronic medical records can help provide copay information for certain coverages.

Implementation

This can be the most complex phase for many with COPD, as multiple-inhaler therapy can be tricky. I often think of one particular story from my primary care days, with someone using one inhaler that required one puff twice a day and another two puffs once a day. This person had some cognitive barriers and we worked for months practicing, writing reminder cards, everything we could think of, because they were using every dose permutation but that. That is also not taking into consideration the differing inhalation techniques of the two devices. Be sure to use techniques like the teach-back method and regular follow-up to ensure what you have taught is sticking and your patient is fully able to use the tools they are given.

Persistence

In my experience, this can be the stickiest wicket. People would often come back after a month or so and tell me, “Hey, that inhaler you prescribed didn’t do anything, so I stopped taking it.” I used the COPD Assessment Test (CAT) to establish a baseline prior to therapy, and improvements in the patient’s CAT score can be used to point out subtle improvements in quality of life. Follow-up spirometry may also demonstrate improvements, and gentle reminders that most people cannot feel their blood pressure or diabetes medicine “working” can also break through resistance.

Former Surgeon General C. Everett Koop famously said, “Drugs don’t work in patients who don’t take them.” However, it is not enough to know that a patient isn’t taking them. It is equally important to understand why a patient isn’t taking them. Only then can you work together to find a path toward better adherence.

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