Ain't Misbehavin' - Pharmaceutical Executive

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Ain't Misbehavin'
Missing doses and other medication meddling are often no accident. A new study of patient compliance uncovers methods to the madness.


Pharmaceutical Executive


Compliance by Condition

The diagnoses for which participants were being treated run the gamut from constipation to cancer. But predictably, the most common problems were those that top America's chronic-care agenda: high cholesterol, allergies, cardiovascular concerns, arthritis, gastrointestinal issues, and psychological complaints (see "What Ails Them?").

As for specific adherence patterns, the good news is that in general, people who had very serious medical conditions were less likely to be noncompliant—at least with meds for that particular problem. The highest rates of nonadherence were reported by folks with depression or another psychological condition (26 percent), who both raised and lowered daily doses apparently by a personal calculation of baseline emotion or mood—despite the fact that consistent drug levels need to be maintained for optimal effects. One possible solution would be to formulate extended-release versions of antidepressants to replace daily with weekly dosing.

Patients with high blood pressure and other heart-related issues, although less likely to underdose, were among those most likely to practice double-dosage splitting. Of the prescriptions being double-dosage split, 38 percent were cardiovascular drugs.

The form of the medication (tablet, capsule, or softgel) appeared to have no influence on noncompliant behaviors. The only exception, understandably, was that double-dose splitting of pills was done exclusively with tablets, as capsules cannot be split.

Two-Way Split

Double-dosage splitters tend to be cutting costs, while single-dosage splitters tend to be saving money. It's a subtle but significant difference.

The double-dosage splitters, who get a prescription for twice the required dosage amount and then split the pills to take half each time, do so in the spirit of a savvy consumer: With flat pricing for prescriptions becoming more commonplace, fifty 300-mg tablets can often require the same copay as fifty 150-mg tablets. It's worth noting that most people were informed of this money-saving method by their doctors. And this group scores average or better on income and insurance coverage—these folks are less likely to need to save on meds and yet more likely to do so.

By contrast, single-dosage splitters are at the other end of the economic spectrum—poorer and with less access to insurance or drug coverage. Their reasons for slicing their pills and underdosing are evenly divided between, on the one hand, saving money and, on the other, reducing side effects and long-term safety risks. Most say they came up with the idea on their own, do so only some of the time (as opposed to the regimented approach of double-dosage splitters), and do not use a special splitting device.

Industry Insights


What Ails Them?
The study's findings should serve up plenty of food for thought. For starters, one very practical application is in the calculation of "compliance-adjusted days of therapy" used by pharmaceutical companies in forecasting market potential for a new drug. Because these multipliers typically account for only the frequency of unintentional improper dosing, the new variables exposed by this survey may help make these calculations more relevant.

The study also reveals surprising data with respect to how little it takes to turn a previously compliant patient into an ardent pill splitter: 77 percent said they would split if their doctor recommended it, and 59 percent would if their health plan advised it. Of the nonsplitters who said they would split to save money, 40 percent would do so to pocket a mere $15 more per monthly prescription. Clearly policies such as flat pricing by insurers and payers can significantly influence intentional noncompliance.

As for the most important issues—drug efficacy and patient health—the study's focus on intentional noncompliance raises new questions. What if the pill splitting is not done accurately? And for people taking more than one medication, does it add regimen complexity and thus raise the overall potential for error? Is it creating a slippery slope—further encouraging patients to skip dosing to save money?

And while reformulating medications as extended-release versions or two-diagnoses-in-one-pill combos may put the brakes on noncompliance, such innovations will not address the underlying issues—like increasing access to health insurance and drug coverage. Treatments for those chronic conditions, of course, lie outside the lab.

Bill Chekan is director of global marketing for Capusgel. For more information, please contact


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