Pharmacists and GPs are often saddened by the volume of unused medicines returned by patients and simply incinerated. It is money gone up in smoke and many CCGs have put in programs to reduce this. Broadly, and in my opinion, there are two main causes:
Systematic: There is always going to be a level of waste due to systems. Patients like to have a small supply in hand and prescriptions are often written and dispensed in 56 day lots. So a patient may have 60 days of treatment stored in their cupboard when that treatment is discontinued. The way that the repeat prescription system works may encourage a patient to tick all the boxes when in reality they don’t need all of them to be refilled at that time. Some patients may be forgetful or have simple disabilities that make access to their medicines sporadic. And then there are more difficult issues of sharing and diversion to contend with.
There is much to do in this ‘housework’ and ‘education’ and ‘support’ to keep this at a minimum and many examples of these activities in practice.
Individual: For a whole range of reasons an individual may choose not to take a specific medicine or group of medicines without telling their family or their healthcare professional. This is usually based on cognition – the way that patients understand – and mixed with a whole range of cultural influences and beliefs and family relationships. You cannot see these by looking and you cannot correct them by improving health literacy. I actually believe that telling them more of the same stuff may lead to belief entrenchment.
I have blogged about this with respect to diabetes where many of the type 2patients I looked after believed that discussing or moving on to insulin was a sign of failure. Next time you say to a patient – if drug A does not control things (AKA fails) then we can move onto drug B – think about how it might be interpreted and spread.
But you can get an insight into these. Everyone has a cognitive architecture and through selective questioning you can make a judgement on the likelihood to comply. It allows a targeted approach that deals with the cognition.
It might seem crazy, but if you want to know how likely a child will be given ADHD medication regularly, you ask the parents about holidays. If you were planning a holiday – you wanted to go to France and your partner wanted to go to Spain – where would you end up going. It gives an insight into relationships, beliefs and how you target your intervention.
So when patient hands in a bagful of medicines, you should ask – could I have predicted this by assessing cognition?
On the other hand this new science of cognition can lead to increased adherence to medicines. In two conditions an increase of 10% that appears to be maintained over time. If we can measure a change in cognition and associated behaviour at 3 months then we should be able to reflect an improvement in surrogate markers, early improvement in outcomes and predict longer term reductions in health and social costs.