Healthy Skepticism Library item: 9132

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Publication type: news

Cassels A.
Defying your drug regimen - the do's and dont's
Common Ground 2007 Apr
http://commonground.ca/iss/0704189/cg189_drugs.shtml

Full text:

People often tell me the more they learn about prescription drugs, the more their instincts tell them they should disobey their doctors’ orders. But they also wonder how they can possibly do that.
It’s a tough question, but my answer, in a nutshell, is “sensibly.”
You can never underestimate the importance of obedience in the medical system as we know it. Without people willing to follow their doctors’ orders, it would collapse overnight. Almost.
I say “almost” because the research on patient behaviour around prescription drugs finds that most of us are already fairly skilled at disobeying our doctors’ orders. Take the statins for example; drugs like Lipitor that lower cholesterol and are among the biggest-selling drugs on the planet. Most people don’t take them for very long. Research studies from around the world show that only about half the patients prescribed statins continue taking them for more than six months, and within a year only one third are still taking the drug.
In February, James Le Fanu, famed author of The Rise and Fall of Modern Medicine (1999), published an article in the Sunday Telegraph, relating the story of one of his patients who took a holiday and forgot to take his statins for three weeks. Seemed like the 74-year-old’s aches and pains improved so much he decided that a permanent statin holiday was in order. Le Fanu doesn’t pull any punches when he writes, “Statins are useless for 95 percent of those taking them, while exposing all to the hazard of serious side-effects.” So if you find yourself stopping the Lipitor or the Crestor your doctor insists you need, there is one thing you can be fairly sure of: You aren’t alone.
This defiant behaviour deeply worries the pharmaceutical industry and it spends no small amount of energy and research money on trying to improve your “compliance” or “adherence” and to otherwise get you to keep taking your pills. You can imagine things from its perspective: It has spent millions developing a drug, and even more on convincing people to use it. Now it has to work hard to get people to keep taking it because “non-compliant” patients represent a potentially huge loss of profits.
Strategies to improve compliance or adherence basically reduce peoples’ involvement in their own healthcare to one dimension: Following orders. Whenever I read about or hear discussions around the use of medication and the word compliance shows up, I suspect that Pharma is lurking somewhere nearby.
The research on type-2 diabetes and patient self-management finds that, of all the things they are ordered to do, patients are much more likely to follow their prescribed medication regimen and least likely to follow advice on lifestyle changes around diet and exercise.
Why is this? Well, it’s understandable from the patient’s perspective: If there are a bunch of orders your doctor has given you, you’re likely to do the easiest thing first: Take your drugs. It doesn’t help if your doctor isn’t very good at motivating you or knows very little about nutrition or exercise; doctors get little training in either area.
Yet, for type-2 diabetes, this may be the most irrational thing to do. The best evidence suggests that diet and exercise, unlike the drugs that only modify your blood glucose or cholesterol levels, are proven to go a lot further, improving your overall health and well-being in many different ways.
There’s evidence of non-compliance in the diabetes world, but not only from the patients; it also comes from doctors. The Health Council of Canada recently issued a report entitled Why Health Care Renewal Matters: Lessons from Diabetes, decrying the state of diabetes care in Canada. Among the sins listed was the fact that “Less than half of Canadians with diabetes get all the lab tests and procedures recommended.” Rightfully citing the sorry state of eye exams (which doctors aren’t performing enough to prevent the real-life complications of diabetes), the report also mentions the need for regular monitoring of blood sugar, cholesterol and blood pressure.
Is it possible that our family doctors aren’t ordering more tests or dishing out the full array of drugs we are told diabetics need because they have a little compliance problem of their own? Or maybe both doctors and patients are acting rationally.
Ignoring treatment advice that exposes us to the risk of significant adverse effects, and which makes little difference to the overall length and quality of our lives (and costs a ton of money), might be entirely acceptable. In type-2 diabetes, for example, advice about getting us to eat better and forcing us off our butts to exercise more holds many more rewards than getting us to obsess over our blood pressure or cholesterol. And, by the way, the fact that doctors generally bypass non-drug approaches to diabetes merits a mention by the Health Council: “Less than half of Canadian family physicians report that they refer their patients with diabetes to support services, such as nutrition and fitness counselling.”
Here, however, docs aren’t being non-compliant. Perhaps they are just being pragmatic. Generally, provincial medical services plans don’t pay for lifestyle modification for diabetes patients. Identified a new diabetic in your practice? Great. A free sample of Lipitor might be the only thing you can think of to get him out the door. Compliance strategies employ lots of new, whiz-bang information technologies to keep an increasingly close eye on your medication-taking habits. Rx Canada, which bills itself as a “provider of e-health adherence solutions for pharmacy” is but one example of a group leveraging information technology for “medication management and support.”
Another company, MediVoxRX, in Pittsburgh, has developed Rex, the “talking pill bottle,” which plays back to you, in your pharmacist’s own voice, microchip-stored prescription information, from a little speaker on the bottle. Other adherence technologies can track how many times a day a bottle has been opened, and can gather your blood pressure and blood glucose readings and wirelessly and seamlessly send them to your doctor or caregiver. Pretty soon, it’ll be more than Santa Claus who knows when you’ve been bad or good.
The whole problem with compliance in medicine is that we assume nothing bad can come from following orders. The work of Dr. Stanley Milgram, the famous psychologist who published Obedience to Authority in 1974, reminds us how far people will go to please authority. Participants in his studies were told to administer electric shocks of increasing intensity to a “subject” – Don’t worry! It was an actor faking it – for getting wrong answers on a quiz. Many participants complied with his order, sometimes even until the subject appeared to be unconscious.
We all grasp at excuses for our lapses in judgement, but using the “just following orders” explanation to justify inflicting suffering on someone says tons about the complex human psychology around obedience.
This is troubling not just from the perspective of the patient, but also from that of the physician, who could also say that she is just following orders provided by guideline committees or professional organizations when she chooses to put you on a new drug or subject you to a new test, even if it might cause you harm.
At the end of the day, can you afford to be choosy in deciding which bits of your doctor’s advice you want to obey? Yes, but only if you decide sensibly. Any decision about treatment must incorporate two key things: Informed consent and your personal values. Deciding on whether you even want to be treated in the first place, given a full understanding of the risks and benefits, is vital. You don’t want to take drugs, change your diet or exercise? Fine, that’s your choice. But you can only make that choice after you are made aware of the benefits and harms related to the entire spectrum of interventions, as well as the costs involved and the alternatives, if any.
With the majority of conditions, there’s no hurry to take a prescription. You can take your time and do your research. If it’s type-2 diabetes or high cholesterol you’re worried about, you need to be informed and know your options, because you could very well be put on drugs for a really long time.
Luckily for us, new doctors coming out of medical school learn a new word: It’s called “concordance,” a much more enlightened way to deliver and accept medical advice. It’s about agreement between a doctor and an informed patient. It is what drug decision-making should be about.
If we want to achieve rational health care in our society, we’d best put compliance where it belongs: in the dust bin of history.

Alan Cassels is co-author of Selling Sickness and a drug policy researcher at the University of Victoria. He is also the founder of Media Doctor Canada, which evaluates reporting of medical treatments in Canada’s media. www.mediadoctor.ca