Detection of False Medication Adherence

Introduction

Treatment noncompliance, as well as medication adherence, constitutes an important problem that affects both: the healthcare system and the patient [1]. To the healthcare system, because patients need new medical visits, new treatments, hospital admissions, etc. To the patient, because they feel unsatisfied for not meeting their health expectations.

So, you may ask yourself why the patient not complies; since really, both parties want the best of health.

Understanding the problem at its root requires to pay attention to the language, to the patient’s speech — for the simple reason that pharmacotherapy is immersed, embedded in the patient [2]. In other words, we go from the scientific, as medication is, to its application or social consumption, the patient. This union of the scientific and human, the medication and the patient, requires a mutual understanding between pharmacist and patient.

The pharmacist in professional practice, has an active role that promotes changes; uniting theory and practice, science and social, medication and patient. Thanks to language, speech and experience communication that the patient has of the medication, we can learn about the problem of noncompliance and understand it.

Method

Being the pharmacy office — a shared place between patient and pharmacist, means the pharmacist can talk to people and make questions. Thus, the pharmacist increases knowledge of experience patients have regarding their pharmacotherapy and health.

For this reason, the method of choice is ethnographic of direct observation [3], specifically “participant observation” centered on the patient. Participation in the investigation is double, the investigated and the investigator come into play. Not only scientific knowledge is asked of the pharmacist, but also affective, communicative, sensory, empathic qualities... without value judgments. Because conversation [4], language and the experience should be informal in order to maintain good rapport. Research conditions is what will allow to discover significant signs of noncompliance or lack of adherence, how it is organized and how it is carried out by the patient.

Cases

• Woman, 28 years old. Level of education: high school. She goes to the pharmacy for her birth control pills; she has been taking them for three months.

She complains about having to take the pill each night and considers it bothersome. Since we agreed (using body language) with her complaint, she ventures to ask what would happen if her husband or three year old son took a pill. Upon responding that absolutely nothing, her expression changed from weariness to happiness, while asking with enthusiasm: if being three years old the child, should there be two or three pills at dinner; that it would be lucky for her, since she would not have to prepare two different dishes for dinner because of the pill. In other words, making only one dish for dinner and adding three pills in the cooking pot, or sauce pan.

Calmly even an easier “trick” was suggested: to place the pill inside of her mouth and to swallow it with a glass of water.

With all the misuse of the medication, the woman did not become pregnant.

• Woman, 75 years old. For about 10 years she has been in treatment only with 5 mg of Clorazepate Dipotassium for problems of anxiety at night. Recently she has been added 10 mg and now she comes to withdraw a prescription of 15 mg. while complaining that the medication has no effect. However, the doubt about its ineffectiveness — not being credible — and the suspicion of a poor administration arises. She is asked to explain step by step how she takes the medication, but answers repeatedly: “One at dinner.” Now, we ask her to come take the medication at the pharmacy, shortly before closing.

We begin from cero; she is provided the closed package and a glass of water. She does absolutely nothing; she looks at it with astonishment. She states that it is impossible to take it because she has no dinner. We take a capsule out of the container for her and offer it with a glass of water. She holds the capsule in one hand and in the other, the glass; she continues to be astonished. She is told to insert the “capsule” in her mouth and to swallow it drinking water, as if she was very thirsty. “Are you sure this is how it is done?” “I have never done this before.” It was the first time in her life that she swallowed a capsule. She had been emptying the content — because she thought it was plastic — in the cooking pot where the soup was being made every night to comply with the treatment prescribed: “Take at (with) dinner.” She began the initial 5 mg treatment again, this time “correctly,” being this one efficient.

Discussion

Therapeutic noncompliance was detected in the first case, by body language, exactly by facial expressions of displeasure and/or disagreement, accompanied by some guttural sound; in the second case, by intuition or professional praxis, in which the possibility of not being credible the ineffectiveness opened up by something yet to be discovered. Finally, it was discovered by asking to take the medication in the pharmacy, starting from “point zero.” That is to say, handing the sealed medication — without opening — to observe the whole process.

The language, the dialogue, was always conducted with patient-centered attitude. Favoring the pharmacist an observant mindset for the purpose of discovering the patient’s experience with the medication, and promoting the most important: the patient’s trust. This perspective allowed contrasting with the expected, thus it was possible to propose consensual changes in both patients.

The expression of the word “trick,” was of daily use in this social-pharmaceutical context. The word was used to explain the optimal use of the medication to maximize the benefit of the patient’s health, without resorting to reproaches. The word “trick” opened the dialogue for us to reach a consensus. Thus, avoiding these way two false ineffectivenesses attributed to medication, in which one of them could have reached a complaint for unwanted pregnancy.

Comments

The surprising discovery of how the phrase “take one at dinner” was interpreted, motivated us to investigate and discover new cases in which all were gradually resolving. Additionally, we learned to express ourselves in a more appropriate way, not only with the simplicity of “one at dinner,” but with good work from the very beginning. This is how other problems of false compliance and adherence to treatment were detected: not removing the cap of the inhaler, eternally refilling the suspension bottle (antibiotic), etc.

What all had in common, is that they passed as dutiful and compliant in the tests of treatment adherence [5]. But the dialogue, the informal language in that common context and environment between patient and pharmacist — such as a pharmacy, revealed not only the lack of compliance, but the beliefs and thinking or interpretation of the patient.

Conclusion

Direct observation through language and dialogue — always informal and focused on the patient, in a climate of trust, allowed to discover: not only unexpected therapeutic noncompliance of the patient, but the opportunity to reconstruct in a consensual manner, adhesion to treatment.