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The evolution of pain medicine adherence [extract]

Pain medicine adherence, the extent to which patients follow a treatment plan for managing pain, has remained a challenge to doctors and patients alike for millennia. Risks abound, from not taking enough medication, to taking too much and/or becoming dependent on it, with the current opioid epidemic in the United States providing a clear example of the latter in action. The following edited extract, from Facilitating Treatment Adherence in Pain Medicine examines the history of pain medicine adherence, from ancient Greece to the present day.

In 2003, the World Health Organization published the document Adherence to Long-term Therapies: Evidence for Action. The issue of adherence was addressed in a number of disease-specific reviews, including, asthma, cancer, depression, palliative care, diabetes, epilepsy, HIV/AIDS, hypertension, tobacco smoking cessation, and tuberculosis. Missing was the area of chronic non-cancer pain, which affects approximately 30% of the American population and costs $560 billon to $600 billion per year in the United States. This impressive volume of work by leaders in their various areas of expertise generated a number of “take-home” messages that are particularly salient to the discussion of adherence with regard to pain-related healthcare outcomes:

• “Poor adherence to treatment of chronic disease is a worldwide problem of striking magnitude.”

• “The impact of poor adherence grows as the burden of chronic disease grows worldwide.”

• “The consequences of poor adherence to long-term therapies are poor health outcomes and increased healthcare costs.”

• “Improving adherence also enhances patient safety.”

• “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”

• “Patients need to be supported, not blamed.”

• “Health professionals need to be trained in adherence.

Dating back to the earliest Western writings about patient behaviour, the willingness or ability of patients to follow a recommended treatment plan has been recognized as an important issue—and one that in contemporary times is a major determinant of health-related outcomes. Hippocrates cautioned his contemporaries to “Keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed. For through not taking disagreeable drinks, purgative or other, they sometimes die.” In modern times, healthcare providers continue to be concerned with issues of patient compliance and nonadherence to treatment regimens but often feel ill equipped to influence it. In undergraduate and postgraduate medical education, little is taught about this critical issue.

‘Adherence depends on a strong clinician–patient therapeutic alliance and developing a trusting relationship that is based on collaboration’

Surveys of healthcare providers indicate that one of the most distressing features of clinical practices is that of patient nonadherence. Oftentimes the words compliance and adherence are used interchangeably, but they really do denote very different levels of intent. Compliance refers to the extent that patients are obedient to prescriptive instructions of healthcare providers, thus suggesting that noncompliance is a volitional act of disobeying salutary recommendations. Adherence implies a more active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behaviour to produce a desired preventative or therapeutic result.

The World Health Organization defines adherence as “The extent to which a person’s behaviour taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider.” It was R. B. Haynes who succinctly brought into clear focus the relevance of this clinical construct, stating that “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”

But through the lens of history and patients’ perspectives, there may be unwitting survival benefits of nonadherence. A century ago Chapin (Charles V.) commented on the state of medical care at the time, averring, “We might not be surprised that people do not believe all we say, and often fail to take us seriously. If their memories were better they would trust us even less.” Iatrogenic complications of treatment and frequency of adverse drug effects continue to be commonplace. And with the advent of the Internet and direct-to-consumer advertising, patients are receiving a barrage of information regarding medical care that can cause scepticism, erode the patient–physician relationship, and increase the rate of nonadherence.

Notwithstanding—but clearly recognizing—these very real concerns, and within the personalised context of each patient’s individual circumstances, considerations of adherence must be aligned with and tied to the patient’s treatment goals and objectives, self-view and perceptions of quality of life, adjustment to an acute or chronic condition, ability to cope with illness over time, social support systems, and ability to make autonomous decisions. Adherence depends on a strong clinician–patient therapeutic alliance and developing a trusting relationship that is based on collaboration. It is also becoming clear that this necessary therapeutic alliance is far from sufficient to guarantee adherence. Many other factors are determinative, and perhaps predictive, of adherence. But oftentimes, nonadherence can be attributed to a breakdown of the therapeutic relationship, a misunderstanding of instructions from the healthcare provider, or barriers within the healthcare system itself.

Featured image credit: ‘Glass bottles with labels’ by Daria Nepriakhina. Public Domain via Unsplash.

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