The following guest post on the subject of drug adherence is written by Joyce A. Cramer. Joyce is Associate Research Scientist at Yale University School of Medicine as well as President of Epilepsy Therapy Project, a 501-c-3 organization accelerating new therapies for people with epilepsy.

“Drugs don’t work in people who don’t take them” said former Surgeon General C. Everett Koop. While performing research on this topic since the 1980s, I have been continually surprised that the results are uniform: People take, on average, three-fourths of medication as prescribed¹. This has held true across many diseases and types of medications. There seems to be no consequence so severe that everyone with that disorder takes all doses (e.g., organ transplantation, epilepsy, asthma, etc.).

One of the first studies I published included extensive neuropsychological testing. It showed that not taking all doses does NOT relate to intelligence². There are numerous studies showing the ineffectiveness of health education. Many people get good scores on knowledge linking disease control/management with medication, but do not carry-through by taking all doses.

Interviewing lots of people led me to realize that the main reason is forgetfulness (on a daily basis or during a disrupted schedule). I then developed a simple system to teach people skills on HOW to take their medication. It consists of asking the person (a) what is the best time of day to remember a dose, and (b) what daily activity can you link this to as a reminder³? Typical responses are the best time is in the morning (ask to set a range of time, i.e., 7-8 am), and link it to making coffee, taking the dog for a walk, etc. Only the person who is taking the medication can select the most convenient time and the personalized cue. The “Cramer Method” does work, as demonstrated in several studies.

The system works only when the person has accepted the diagnosis and need for treatment.

On the medical side, I teach doctors to ask whether the person is willing to take the medicine, then proceed to teach them how to set time and personalized cues. Explain that if the first cue does not work well, select another cue.

I often hear that someone had an exacerbation of symptoms after missing doses or discontinuing treatment. Sometimes the same person has multiple episodes until the personal lesion is learned. That’s human nature. I do not look at medication adherence as a complex behavior mediated by psychological issues. Much of it is a straightforward personal commitment based on choice, coupled with acceptable tactics to do what is being asked. Diseases differ in requirements, ranging from one tablet daily for hypertension to diet, exercise and oral or insulin treatments for diabetes. People differ in their willingness to perform health-related tasks – changing over time based on other priorities in their lives⁴. Yes, people make choices for which they are responsible, both actions and inactions. The doctor can’t make it happen without a willing partner.

1. Claxton & Cramer. Medication compliance: the importance of the dosing regimen. Clin Therapeutics 2001; 23: 1296-1310.
2. Cramer et al. How often is medication taken as prescribed ? A novel assessment technique. JAMA 1989; 261:3273-3277.
3. Cramer & Rosenheck. Enhancing medication compliance for people with serious mental illness. J Nervous Mental Dis, 1999; 187: 52-54.
4. Cramer et al. Compliance declines between clinic visits. Archives of Internal Medicine, 1990; 150:1377-1378.

This entry was posted on Friday, October 23rd, 2009 at 6:34 am and is filed under Drug Adherence, Guest Posts. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.