Doctors' orders often ignored

March 17, 2002|By Charles Ornstein | Charles Ornstein,Special to the Sun

Medications: Even the threat of contracting anthrax isn't enough to get some people to take their prescriptions the way they're supposed to.

Deborah Willhite, who helped formulate the U.S. Postal Service's response to last fall's anthrax attacks, stopped taking her antibiotics two weeks before her 60-day prescription ended.

Willhite, an agency senior vice president deemed at risk for anthrax exposure, couldn't stand the vomiting, an occasional side effect of the medication. The last straw was throwing up in a store parking lot while she was loading packages into her car.

"I heard a couple rolling by me with a shopping cart saying, 'Isn't that the lady with the Postal Service that's on TV all the time?' " she recalled. "That was the last day I took doxycycline."

Willhite acknowledges that she should have been a role model for medication compliance. But instead she acted like many American patients, whether they face anthrax, angina or asthma: She took prescription drugs when and how she saw fit.

Actually, she was among the more compliant of the 10,000 people at highest risk for anthrax exposure in Florida, New York, New Jersey and Washington.

In New York City, for example, health officials say as many as half of those prescribed anthrax antibiotics never took a single dose -- even though the disease had proved rapidly deadly and the drugs were free.

"If your co-worker died of the disease, and you know that there are spores in your environment, ... and you still don't take the medication, imagine how much of a bigger problem we have for things that are less in your face, like your blood pressure and your cholesterol," said Dr. Jerome Avorn, an associate professor of medicine at Harvard Medical School.

Research has shown that the problem extends far and wide -- to patients who are on the verge of blindness from glaucoma and those who have just undergone life-saving kidney transplants. Even women trying to prevent pregnancies routinely miss one or two doses of their birth-control pills each month.

Overall, about 50 percent of people don't take medications for chronic conditions as ordered by doctors. It's "a dirty little secret in health care," said Avorn, who has written extensively about the issue.

The reasons patients cite for stopping -- or never starting -- medications are varied. Some feel fine without the drugs. Some simply forget. Others don't have money or insurance, or the side effects are too much to bear.

And then there are many people who foul up the timing of their drug treatment -- and then try to compensate for skipped doses by taking more.

Compliance is particularly important with antibiotics, which work by attacking bacterial cells within the body and preventing their ability to reproduce. If the drugs are taken inappropriately, they kill only some of the bacteria, allowing remaining cells to thrive and develop resistance to those antibiotics in the future.

Completing a prescription generally kills off all bad bacteria, removing those risks.

Doctors usually take for granted that patients will take their drugs as prescribed, but researchers have shown that such assumptions often are wrong.

In one 1986 study, for instance, researchers placed an electronic device in the eye droppers used by glaucoma victims. It tracked every time the bottle was opened and turned upside down. On average, people missed about a quarter of their prescribed doses. But in interviews, patients said they had taken a full 97 percent of their drops.

Other studies have similarly shown that people lie about their habits to stay in their doctors' good graces. In the day or two leading up to a doctor's visit, patients tend to take their medications more religiously, an effect some researchers have called "white-coat compliance."

When patients stray, studies show, some get sicker faster and die earlier. And taking the drugs haphazardly can lead to more health problems than not taking them at all.

Drug companies are trying to bring patients into compliance. The most promising solution is to develop medications that can be taken once a day and that don't produce harsh side effects, said Christopher Dezii, a manager at Bristol-Myers Squibb. This is especially true for patients with complex diseases such as AIDS, who sometimes take three dozen pills a day, with rigid rules for each medication.

Insurance companies, too, are concerned because studies suggest that compliant patients have fewer emergency room visits and hospital stays. Aetna Inc., for instance, sends out quarterly letters to 20,000 primary-care doctors listing members of health maintenance organizations who were late refilling prescriptions for high blood pressure, high cholesterol, congestive heart failure, asthma and diabetes medications.

Aetna also sends an instant message to pharmacists if members come to pick up a refill a week or more after they were supposed to.

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