Medication Nonadherence: The Most Costly Drug Is the One They Are Not Taking

Nonadherence to medication is pervasive across healthcare, and the backdrop of workers’ compensation presents unique challenges to consider when managing treatment. Opioids and other products with abuse potential open the door for aberrant drug behaviors as a patient relies on these drugs to deal with symptoms or emotional stress of injury while abandoning medications that can better restore functionality —resulting in delayed return to work, poor health outcomes, and higher costs for the payer.

When it comes to achieving successful treatment outcomes, choosing the right medications is only half the battle. Treatment effectiveness does not solely rely on the number or types of medications prescribed. Yet when a patient’s condition fails to improve, his or her drug regimen becomes the primary culprit. Should the dose be adjusted? Should another drug be considered? The appropriate selection and prescribing of medication is one of many factors that should be addressed when assessing outcomes in injured workers. But before any regimen changes are made or new prescriptions written, there’s another critical question that demands consideration: Is the patient taking their medication correctly to begin with?

Statistically, there is a high likelihood that they are not. Nonadherence to medication is a serious and pervasive problem. Of the 3.2 billion presciptions dispensed annually in the United States, only half are taken as prescribed.¹ And the consequences of nonadherence go beyond medication ineffectiveness to cause added harm. Reduced quality of life due to adverse effects of medication, exacerbated condition symptoms or complications, disease progression, premature disability, and even death are all potential outcomes of a patient not adhering to their prescribed treatment regimen.² The Centers for Disease Control (CDC) estimate that treatment failures from nonadherence cause about 125,000 deaths annually in the United States.³

Compounding Effects of Medication Nonadherence^1,4,5

While patients are suffering, so are payers’ pockets. The negative health consequences of missing doses or taking medication inappropriately translates into higher medical costs for payers in the form of excess hospitalizations, extra physician office visits, wasted pharmacy costs and polypharmacy.² Beyond workers’ compensation, the numbers are staggering: medication nonadherence is estimated to cost the overall health care system and society upwards of $100 billion per year.^1,4

Simply put, the cost of not following “doctor’s orders” is high — both in lives and dollars. However, the reasons for nonadherence are myriad and complex.⁴ This holds true across the healthcare spectrum, but workers’ compensation presents some additional and unique challenges when it comes to the overall management of drug therapy.

Nonadherence in Workers’ Comp

Workers’ compensation programs are designed to promote functional restoration and return to work by eliminating direct financial barriers to treatment. However, this construct — while altruistic in nature — may give rise to new and different drivers of nonadherence not typically seen in the group health setting.

The lack of financial responsibility for the injured worker can translate to a reduction in self-responsibility. Without the burden of out-of-pocket costs, a patient may become less motivated to follow the treatment plan that best expedites functional restoration and return to work. Instead, the focus of the injured worker becomes palliation, opening the door for selective adherence. The potential for this behavior is strengthened by the very nature of workplace injuries and their associated treatments. Opioids and other medications commonly prescribed under workers’ compensation are designed to address symptoms rather than underlying disease conditions. So it is not surprising that a proportion of patients elect to take the medications in their regimen that mask pain, while disregarding therapies that more effectively address healing over the long term (see adjacent sidebar on chemical coping).

Strategies for combating nonadherence in the injured worker population must address psychosocial factors that are unique to the population. Absence of a financial stake in the treatment process poses the risk that a patient will have a lower emotional investment in treatment-related decisions, but there are also non-financial barriers to consider. Injured workers are more likely to suffer depression than their noninjured counterparts — 45% more likely, according to a post-analysis of nearly 368,000 injured and noninjured workers.⁶ The feelings of hopelessness that come with depression may contribute to a “why bother?” mindset that deters adherence. This may explain why depression as been shown to impact time to recovery and/or return to work, even in the case of minor injury, as well as increase cost of treatment.^6,7

Drivers of Non- or Selective Adherence in Workers’ Comp 

The Role of Monitoring in Adherence

Appropriate medication prescribing and adherence work hand-in-hand to drive successful outcomes. But the two components differ in one crucial aspect: medication regimens may change, but adherence is a constant endeavor. An injured worker may experience medication switches, dose modifications, changes in health condition or quality of life, battles with drug dependence — the potential drivers of nonadherence are numerous. Despite the changes, there remains the need and the expectation for sticking with the treatment plan.

This is a tall order, especially for an injured worker who is facing other challenges such as disruptive changes in lifestyle due to sudden injury and/or loss of function, or the stresses that come with potential loss of income. The World Health Organization (WHO) asserts the position that responsibility for maintaining adherence should not fall fully on the shoulders of any patient.⁸ Arguably, this positioning is especially relevant within the injured workers population, which already struggles with inherent barriers to adherence.

Ideally, a strong foundation for successful treatment may be established through the physician-patient relationship. While it is the physician’s role to prescribe, adherence to these medications is best achieved through a collaborative approach in which there is shared responsibility; meaning that patient and physican are equally accountable for ensuring that the treatment plan is being followed.

This sharing of responsibility, however, should not be limited to physician and patient. Other stakeholders, such as a pharmacist or a pharmacy benefits manager — can and should play a role in monitoring and managing adherence. The unique challenges of workers’ compensation and the risks these challenges pose to adherence further underscore the critical role of an ongoing and inclusive approach to monitoring.

Singular monitoring practices, such as reviewing prescribing history, provide only a narrow view of a patient’s case. Pharmacy records provide refill patterns, which can help identify early or late refills that may suggest inappropriate adherence patterns. Drug screenings can indicate the presence of prescribed drugs with abuse potential, as well as non-prescribed or recreational substances that may detract from adherence to the prescribed treatment plan. While these are valuable pieces of information, on their own they are just that — pieces. The best approach is to use a combination of monitoring practices in order to form a more complete picture of patient adherence.

Turning Information Into Action

Comprehensive data exist, but become meaningful only with the proper analysis and follow-through. Therefore, it comes as no suprise that the most effective evaluations are rooted in cross-functional review and communication. A conversation between physician and payer can uncover concerns that may be undocumented or unclear in the paper trail. A clinical pharmacist can lend their expertise through a regimen review to identify unnecessary polypharmacy or other complexities in drug regimen, providing guidance to the prescriber.

Above all, every patient is unique. There is no one-size-fits-all approach to drug adherence monitoring or overall treatment management. The most appropriate combination of monitoring practices should be applied to a given case in order to obtain relevant and actionable information.

Chemical Coping: Too Much of a “Good” Thing

Successful application of adherence monitoring strategies means knowing what to look for. But evaluation of opioid use or misuse is rarely black and white. The population of patients taking opioids is not conveniently split into two groups — those exercising appropriate usage and those who are dependent or addicted.

Chemical coping is a broad term used to describe the expansive gray area between proper, nonaddictive opioid use and addictive behavior.^9,10 Most chemical copers fall somewhere in the middle and take opioids — drugs designed for physical pain — to cope with negative emotions, such as the stress surrounding an injury or life-related challenges.^10,11 Oftentimes, these patients incorrectly perceive their emotional pain as being physical.¹² Chemical copers typically practice selective adherence, relying on opioids as their sole form of treatment. In fact, the most prominent indication of chemical coping is the patient’s unwillingness to include nonpharmacologic approaches to care in their treatment.¹³

While chemical copers can include addicts, the two terms are not synonymous. In fact, most chemical copers are not addicted.¹² Addiction is a chronic and neurobiologic disease in which patients sustain long-lasting changes in the brain. Addicted patients exhibit compulsive drug-seeking behavior and use opioids daily to avoid withdrawal symptoms, despite harmful consequences.^14,15

There are some traits that put patients at higher risk for chemical coping, including a history of alcoholism or substance abuse, presence of mental or psychiatric disorder, high emotional expression, or limited coping mechanisms.¹³ However, given that chemical coping covers such a large middle ground, there is a need for comprehensive monitoring strategies that can take a variety of factors into consideration.

If chemical coping is determined to be in play, opioid use should be closely monitored, especially during periods of emotional stress. Shorter-term management of chemical coping may include rehabilitative and psychological interventions for providing alternative forms of coping, and simplification of drug regimens that rely primarily on long-acting opioids to avoid “pill popping” with short-acting agents.¹¹ A multi-disciplinary approach incorporating psychotherapeutic intervention will provide long-term benefits for chemical copers.¹³