Harvard Heart Letter

Make peace with your prescriptions

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Heart medications don't work if they aren't taken as prescribed.

Don't sabotage your health by not taking your medications.

Harvard researchers have concluded that up to 80% of people—including more than half of people who've recently had a heart attack—don't take their medications as prescribed. They haven't been able to overcome the many barriers to taking their medicine as they should, when they should, and as often as they should.

Not long ago, doctors tended to blame their patients for this so-called "noncompliance." Now there's a new term—"nonadherence"—reflecting an effort to understand and confront the many reasons so many people with heart disease have a hard time taking the medicines they need.

"If adherence were such an easy problem, we would have solved it decades ago," says Dr. Niteesh K. Choudhry, associate professor of medicine at Harvard Medical School and an expert in medication adherence. "Patients clearly have a central role but cannot be wholly responsible for the solution."

Barriers to adherence:
Medical systems

There are different ways people may be nonadherent. Some take their pills erratically, forgetting to take the proper dosages or deliberately taking their pills every other day. Some take their medications like clockwork for a while, and then stop. Some never even get their prescriptions filled.

Not taking medications properly is just as big a problem for people with acute, life-threatening conditions—such as a recent heart attack—as it is for people managing chronic conditions, who must faithfully take pills for the rest of their lives.

Cost is a big part of the problem. "Affordability—what people pay out of pocket—is a big barrier," Dr. Choudhry says. "Let's get people on medicines that are lower-cost but equally effective. People should ask their doctors about the costs of the medications being prescribed, which may influence the prescriber's choices. A lot of times prescribers don't think of cost as the most relevant issue."

Dr. Choudhry also suggests that insurers should do away with co-pays for the most effective drugs, as even relatively small co-pays are a surprisingly high barrier even for people with very good insurance coverage. Even when prescriptions are affordable, getting to the pharmacy to fill them is a challenge for many people because of location, their advanced age, or their frailty. And complex drug regimens—take this pill three times a day with food, take that one every 12 hours on an empty stomach—can make it difficult or impossible for even the most committed people to take their medications perfectly.

But even if the wave of a magic wand suddenly made prescription drugs affordable and accessible to everyone who needed them, and if doctors were able to prescribe simpler regimens, Dr. Choudhry estimates that adherence would go from the current 50% to only 70% or so.

"That will not get us to the 95% adherence that is our goal," he says.

Behaviors and beliefs may be barriers

When we think of interacting with the health care system, most of us think of the few times each year we see a doctor or a nurse. But it really happens every time we take a prescribed pill.

"You see the doctor only a couple of times a year, but you put a pill in your mouth every day or even many times a day," Dr. Choudhry notes. "It is a reminder of the illness you are trying to combat."

That constant reminder can be difficult to face, especially if the pills don't appear to "do anything." It's not like taking a pain pill and feeling your pain melt away. You can't feel your cholesterol levels dropping, let alone the way lower cholesterol levels prevent, slow, or reverse atherosclerosis. For some, the benefits of pill-taking are only theoretical, while the pill itself reminds them that they are "sick" or causes side effects.

Heart disease, especially severe heart events, can bring on bouts of depression and post-traumatic stress disorder, both of which seem to reduce adherence. Even warnings about possible side effects may be stressful and reduce adherence.

Dr. Choudhry doesn't downplay the many issues beyond a person's control that make adherence hard, nor does he blame people for being nonadherent. Drug costs, pharmacy access, and regimen complexity are major parts of the problem. But ultimately, he says, people have to make peace with their medications.

"This means accepting that these medications are a part of your life—there is no getting around grappling with the idea you have a chronic disease," Dr. Choudhry says. "You say, 'Hey, this cholesterol drug may actually prevent me from having another heart attack; this blood pressure medicine may keep me from having a stroke.' Keep your eye on the prize: along with healthy eating and exercise, adherence is part of the plan to achieve a longer, healthier life."

Do you have trouble taking your medications?

Overcoming barriers to taking medications takes more than organization and willpower. It means knowing the nuances of your heart disease and heart risks and understanding how your medications work. If you answer "yes" to any of these questions—known as the Morisky test—talk with your doctor about why you need your medicines and about what makes it hard for you to take them as prescribed.

  • Do you ever forget to take your medicine?

  • Are you careless at times about taking your medicine?

  • When you feel better, do you sometimes stop taking your medications?

  • Sometimes if you feel worse when you take the medicine, do you stop taking it?