Ain't Misbehavin'

Missing doses and other medication meddling are often no accident. A new study of patient compliance uncovers methods to the madness.
Feb 01, 2007



One mystery of human nature is why so many patients can't seem to take their pills properly. What's not in question is the size or seriousness of the problem. Half of all folks in the developed world who have a chronic disease don't follow their medication's dosing, scheduling, or other requirements. On top of the estimated 500 million prescriptions a year that go unfilled, another 500 million are not taken correctly. A mountain of studies have confirmed noncompliance's negative effects on everything from drug effectiveness and patient mortality to healthcare costs and pharma revenues. The World Health Organization has stamped nonadherence "a worldwide problem of striking magnitude."

The drug industry has stepped in with a diverse genre of "take your medicine" messages, from mass-market TV spots for hypertension pills to personalized Vodaphone IMs to diabetic teens. With other direct-to-consumer advertising coming under increasing scrutiny, treatment-adherence marketing is a way to do well by doing good.

A new study approaches the challenge of breaking the stubborn 50 percent perfect-pill-popping barrier from a fresh angle: intentional noncompliance. The assumption that nonadherence is a result of forgetfulness and other human foibles tells only a small part of the whole story. While much research has focused on patients with high rates of poor drug adherence, little has looked at people who report that they noncomply on purpose, as a result of rational, if flawed, decision-making.

This online survey, conducted last year by Harris Interactive for Capsugel, a supplier of capsules for pharmaceutical and nutritional applications, not only measures intentional noncompliance rates but throws light on the logic driving them. The 1,012 US participants were a representative sample who take at least one pill at least once a day for at least one chronic condition. As such, they represent some of pharma's most highly motivated consumers.

The results are provocative, providing clues for drug developers and marketers to better understand the health consequences, as well as the business ramifications, of intentional noncompliance. To take just one example: A large number of patients who alter their regimen suffer from two or more medical problems. One way for drug makers to decrease noncompliance rates might be to reformulate therapies for different health complaints in a single pill. A combo pill that treats two widespread chronic conditions could take advantage of the higher compliance that often comes with one disease and "apply" it to the other—a case of two birds with one stone. With at least one in six Americans taking three or more prescription meds, tailoring drug delivery to more specific patterns may prove a valuable innovation.

The Top Trends

Nearly half (43 percent) of survey participants on prescription medications for chronic conditions report being intentionally noncompliant at least once in the past three months (see "A Dose of Reality").


A Dose of Reality
The five most common behaviors are: skipping doses or taking too-few pills (16 percent); taking other meds, such as vitamins or supplements, without telling a doctor (16 percent); double-dosage splitting, or getting a prescription that is twice the required dosage, then splitting the pills and taking half (11 percent); delaying a script refill (11 percent); and single-dosage splitting, splitting pills and taking half the required dose (5 percent).

Whether someone is likely to be nonadherent is, of course, influenced by numerous factors, including medical condition, income, and prescription-drug-coverage status. The survey suggests that intentional noncompliance is generally driven by two main needs: to save money or to limit side effects. For example, the results suggest that the lower a person's income, the more likely he or she is to alter dosages or frequencies. However, there's a notable difference between those who take more medication than directed and those who take less: The underdosers are less likely to have prescription drug coverage—and many appear to be trying to make their monthly pill cache last as long as possible.