Wednesday, May 4, 2011

Non Compliance and Non Adherence to Medical Regimen

Non Compliance and Non Adherence to Medical Regimen are terms which refer to the patient part of the physician patient contract. Historically, in the west, all doctors worked as consultants.  Patients were free agents and acted independently.  A patient was most compliant in the surgical sense once they consented to surgery. However compliance could affect surgery very importantly in the post surgical sense.
As a family physician I had many occasions to  reset  fractures and reapply casts because the patient, usually young men, didn't accept that they were injured and proceeded to continue as if nothing had happened.  I have further had patients who post surgery pulled out sutures and re inflicted self inflicted wounds.
The principal area where compliance and non adherence to medical regimen occurs is in the following of recommendations.  The most common is the difficulty people have with taking one antibiotic pill 4 times a day for the usual 10 days required.  Many a pregnancy has occured because a young woman was 'on' the pill but not taking it.
Non compliance and non adherence to medical regimen increase with chronic illness and with mental illness.  30 % non compliance is not uncommon but increases to 50% non compliance with the complexity or longer requirements of the medical schedule.  With mental illness non compliance has been registered as high as 80%.  When a treatment which is voluntary has negative side effects compliance decreases.
Historically if a person didn't follow through with a medication they were accountable for the 'failure of treatment'.  Today in our litiginous society where increasingly no one is accountable non compliance and non adherence to medical regimen is increasingly assumed to be the physicians responsibility.  This goes with the increasing requirement to tell everything about a medication, all the remote but potentially negative side effects, the communication of which decreases compliance.
The shift of responsibility from individual and independent and freedom to state controlled and group consensus is interesting to watch as it plays out in a piecemeal way.  Advertisements for medications on television increasingly tell patients that medications for relatively minor ailments can have lethal consequences. In contrast 'homeopathic' treatments and 'alternative' and 'complementary treatments' may have little negatives, such as massage therapy, but little validity for specific treatment of specific maladies.  Yet massage therapy has been associated with sexual abuse.
In predicting the outcome of a treatment it's important to know what the treatment is, whether it was actually taken, and what is the efficacy of the treatment if it is taken as directed.
This becomes even more important in areas like Addiction Medicine where patients not uncommonly are seeking help because of negative consequences of their behaviour.  Their "solution" would be to continue their "self medication'.  Prochaska has developed "Motivation to Change" in this are. Pre contemplation, Contemplation, Determination and Action phases are identified.  Patient's who are in pre contemplation and contemplation phases are at highest likelihood to be non compliant and not adhere to a medical regimen because they may not identify their problem as their addiction.
I believe the following paraphrase was attributed to Keith Richards, "I don't have a drug problem. I have a cop problem."  In this regard the solution isn't to take antabuse,  revia, attend a 12 step program, see a psychiatrist weekly or monthly but perhaps to see a really good lawyer or becoming actively involved politically to change the laws.  Dr. Bob, the co founder, of Alcoholics Anonymous said, never deny an alcoholics the consequences of their addiction because they only change as a consequence of the consequences.
The more onerous and debilitating and acute a condition is the more likely a person is to comply with treatment.  Gonorrhea is a sexually transmitted disease that can cause a man to feel "like I'm pissing razor blades."  The treatment of choice for gonorrhea is an injection of penicillin. This kills the microorganism and relieves the pain.  However Gonorrhea can go unnoticed and it is much harder to get a person to be 'tested' before being treated on 'speculation' that their unprotected sex with prostitutes might cause them to have an unnoticed infection.
Historically diseases were viewed more acutely and in a limitted fashion.  The above example of gonorrhea would be considered a 'successful treatment' by all involved in the 1950's.  In contrast today in the era of preventative medicine, wholistic medicine, and life style disease management, and wellness clinics, treatment with penicillin would be described as 'symptomatic treatment'.  The potential underlying 'sexual addiction' would be a much harder condition to treat with much worse prognois for successful treatment. Abstinence from prostitutes in the latter scenario would be the 'successful treatment'.
This is seen too in the treatment of cardiovascular risk factors, specifically high cholesterol.  Patients are asked to change their daily behaviour, take a medication for a condition that they don't 'feel'.  Compliance and non adherence to medical regimen are similiarly more common when the condition being treated is asymptomatic.
The birth control pill is 99% effective treatment if taken daily for birth control.  If the same birthcontrol pill is taken monthly it's clearly not nearly so effective, if at all.
Non compliance and non adherence to Medical Regimen are critical factors in assessing or understanding illness and wellness behaviour.

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