4. Medication Compliance and Treatment Session Attendance
Strategies for Handling Medication Noncompliance
This section reviews the most common reasons for medication noncompliance, as listed on the Medication Compliance Plan (Form A–13), Part B, “Review Common Reasons for Pill Noncompliance.” These reasons rank from the topics that are the easiest to discuss with your patient to the topics that are the most difficult. (Note that the reasons are not in order of those most frequently identified with noncompliance.)
Form A–13: Medication Compliance Plan
4.1a. Forgets to Take or Loses Medications. Even people with life-threatening diseases often forget to take their medications. It is not unusual for people to be distracted by other things in their lives and to either forget to take a dose of medication or forget whether they have already taken it. There are ways to combat forgetfulness, but do not assume that patients will develop these strategies on their own. Once you have established that your patient is actually forgetting, not making excuses to avoid side effects or intentionally not taking a dose, tell him/her about the following ways to incorporate the treatment medications into a preexisting routine:
Take the medications when brushing teeth in the morning and evening.
Take medications with morning coffee or vitamins.
Take medications during a favorite morning and evening TV show.
Involve others to witness him/her taking the pills or to administer the medications.
Place notes or other reminders in prominent places such as on a bedside table or bathroom mirror.
Wear an alarm watch that rings when it is time to take the pills.
If the patient loses or misplaces part of a dose, instruct him/her to take a pill from the extra medication doses if provided. If the patient loses an entire blister card but has additional medication cards available, instruct him/her to start with the appropriate day and time of day (morning or evening) using the next numbered medication card. If the patient has no more blister cards, inform him/her to call you or your staff immediately.
4.1b. Worries About Side Effects. Although it seems logical to assume that the most frequent reason people stop taking their medications is because of side effects, in fact, most of the patients reporting side effects with naltrexone or acamprosate are not the ones who drop out of treatment. This is not to say that side effects are unimportant—but if you explain them properly so the patient has confidence in your ability to manage them, this can greatly improve compliance.
Because most patients believe that the only way to stop unpleasant side effects is to stop taking medications, let your patient know in advance that there are several other strategies he/she can try for reducing side effects as long as he/she keeps you fully informed of what he/she is experiencing. Remind the patient about the Patient Instructions for Managing Side Effects handout (Form C–5) you gave him/her at the initial session, and provide another copy if necessary. Try the following steps:
Form C–5: Patient Instructions for Managing Side Effects
Form A–15: Day 3 Clinician Phone Contact
Inform the patient that most side effects are transient and with proper management will likely dissipate.
Tell the patient that if he/she keeps you informed about side effects and the level of discomfort, you will adjust the dosage. This adjustment could be in the form of a temporary dose reduction.
Let the patient know that most people taking these particular medications (acamprosate and/or naltrexone) will not experience any side effects at all.
If your patient is concerned that he/she is not taking enough medication, tell him/her to mention this so you can discuss it. It is a good idea in the first week to call the patient between visits to check on his/her status, both in taking the medication and determining if he/she is experiencing any side effects. Use the Day 3 Clinician Phone Contact sheet (Form A–15) to document this phone contact.
Remember that for some patients, it may be important to determine whether reported side effects are actually linked to the medications or whether they are caused by other factors in the patients’ lives. For example, many patients who have just quit drinking will predictably experience anxiety or sleep or mood disturbances, but they might feel that these discomforts are side effects of the medications they are taking. If you look at the patient’s overall situation and help him/her find alternate explanations for what he/she is feeling, it is likely that the patient will continue with medications instead of discontinuing treatment.
Discuss with the patient the severity and “annoyance” of the side effects. One patient may find a side effect to be unbearable that another finds to be simply bothersome. Talk through the pros and cons of continuing medications. Ask the patient directly about weighing the impact of the side effects on his/her life against the impact of a potential relapse. As always, avoid being accusatory or creating the impression that you want the patient to take medications at all costs. However, you can be helpful in assisting the patient to find reasons to continue treatment, when appropriate.
4.1c. Believes He/She Is Taking Placebo (for patients who are enrolled in research trials). If a patient is concerned that he/she is taking a placebo and not the active medications, it is probable that he/she will stop taking the pills. Therefore, routinely (i.e., monthly) ask the patient to “guess” if he/she is taking the active medications or placebo so that you will know what he/she is thinking. If the patient guesses placebo, explore why and address the reasons in the same session or you may lose the patient. Typically, the patient will relate his/her perception to the fact that he/she is still drinking or dramatically craving alcohol. Therefore, it is important to emphasize that the medications’ effectiveness takes some time to develop and that in some patients, the medications work more slowly. Regardless of what the patient guesses, if he/she is not reporting side effects, he/she may be silently (or not so silently) questioning what he/she is taking. If the patient has not reported any side effects, be sure to say that the absence of side effects does not mean that he/she is taking a placebo. Explain that many patients taking acamprosate and many patients taking naltrexone report no side effects at all. Restate that it is important to keep taking the medications as prescribed and to continue trying to achieve full recovery.
4.1d. Has Misinformation About Medications. Medication noncompliance can also occur when patients have mistaken beliefs about what the medications are supposed to do. For example, people starting on antidepressants may quickly decide that the pills are worthless if they haven’t been educated to the fact that it will take 10 days or more to begin to see any improvement.
Because the primary drug effect associated with naltrexone and acamprosate is an absence (e.g., a reduction in craving, a reduction of desire to drink more if one slips and has a drink), it may be very difficult for patients to know if the medications are having a therapeutic effect, particularly if they experience no side effects and “feel nothing” when they take the medications. To combat this, inform patients that they may not know when the medication has taken effect, but over time, they will see a change in their drinking behaviors. Patients with alcohol dependence are particularly prone to wanting instant effects from their medications; therefore, warn them that neither naltrexone nor acamprosate will be like this. Discuss their expectations thoroughly so that you know what their beliefs are, and correct mistaken ideas about what the medications will and will not do.
Some patients might refuse or stop taking naltrexone because they fear that it will prevent them from experiencing any positive feelings or natural “highs.” Explain that although it is true that naltrexone can sometimes block “runner’s high” and the high experienced by some people after eating spicy foods, it certainly does not eliminate pleasure in most people. The brain is much more sophisticated than this—it has at least three different systems for positive reinforcement, and only one of them is opiate mediated; this is the one naltrexone has an effect on. Discuss these issues openly and honestly with your patients; they are much more likely to be treatment compliant if they know you are not trying to take away their fun in life and that you respect the natural human desire for pleasure.
4.1e. Has Never Liked Taking Pills. Some patients are noncompliant because they are not comfortable with taking any medications at all, even aspirin. Try to address this type of concern proactively by reiterating the rationale of why the medications may be helpful in achieving recovery from alcohol dependence.
Give the patient the patient version of the Naltrexone and Acamprosate Information Sheets (Forms C–1 and C–2) and the Quick Reference Medication Information Grid (Form C–4). Encourage the patient to ask you any questions he/she might have that are still unanswered. (See Chapter 5, “Answers to Frequently Asked Medication Questions.”)
Some patients may feel uneasy about taking medications because they are influenced by the views held by members of a mutual-support group they attend. In this case, give the patient the pamphlet “The AA Member—Medications and Other Drugs” (see Form C–7) and refer the patient to the section stating that no AA member “plays doctor.” Explore with the patient the possibility of his/her participating in and attending specific groups in which members are more tolerant of appropriate use of medication. Reassure the patient about the safety and nonaddicting properties of acamprosate and naltrexone.
Form C–1: Naltrexone Information Sheet: Patient Version
Form C–2: Acamprosate Information Sheet: Patient Version
Form C–4: Quick Reference Medication Information Grid
Form C–7: Name and Location of AA
Pamphlet Relevant to Pharmacotherapy
4.1f. Desires to Drink or “Get High.” Many patients will stop taking their medications for a day or a weekend when they want to drink or “get high.” Some patients do this because they have tested out the medications and found that when they drink alcohol after taking the medications, the pleasant feeling is reduced or absent. Other patients may not want to drink and take pills at the same time and resolve the situation by just drinking and not taking pills.
If this is your patient’s reason for noncompliance, regardless of whether he/she fits into one of the two situations just described, it is important to ask directly about medication noncompliance, taking a nonjudgmental and commonsense approach to helping the patient resolve the issue.
4.1g. Disagrees About Having an Alcohol Disorder or Feels Like He/She No Longer Needs Medications. Many patients refuse to accept the fact that they have a chronic illness or to believe that the condition is bad enough to require medications. Patients may not always express this attitude—it is often something that they think to themselves because they deny the severity of their condition. This may result in medication noncompliance.
To address this issue, provide the patient with all the information about his/her condition and its treatment. If the patient expresses doubt that his/her condition is serious enough to warrant medication, gently but continually remind the patient of his/her presenting symptoms and of the past consequences of his/her alcohol misuse. Emphasize that having an alcohol dependence problem is not the patient’s fault, but also stress that he/she has the responsibility for getting treatment and properly following treatment instructions. Discuss the use of medication as an “aid” rather than a sign of the severity of the problem. After all, most people want to receive state-of-the-art treatment for even a minor problem if they have the option.
Patients who are experiencing a successful recovery, even those who fully comply in the initial phases of treatment, may later decide to stop taking their medications because they feel the problem has been treated and they are now cured and do not need any further “chemical” assistance. They may make this decision on their own—without consulting their medical clinician and typically without knowledge of why continuing medications may be necessary. If your patient has decided prematurely that he/she is “cured,” educating him/her about the treatment regimen is the most helpful technique. Explain that feeling ready to stop treatment before it has gone on long enough to work is common with all illnesses (e.g., antibiotics for a bacterial infection). Stress that making the decision to stop medications should be done as a collaborative effort between him/her and you.
4.1h. Takes Medication at Nonprescribed Times and in “Catchup” Doses. If your patient wants to “make up” medications he/she missed as the result of forgetfulness, lack of organization, and so on, support his/her willingness to adhere to the regimen, but inform him/her that taking the medication at other than the scheduled times could cause problems. Review the Medication Compliance Plan and develop other strategies to help him/her remember to take the prescribed doses if needed.
4.2a. Missed Appointments at Psychosocial Treatment Sessions. Irregular attendance is typical of patients with alcohol dependence. When pharmacotherapy is part of the primary treatment, a patient who misses office visits can also miss 1 or more weeks of medications. This can be much more serious than missing 1 day or a weekend of medications, and you should address it proactively.
When you next have contact with the patient, cover the following areas:
Clarify the reasons for the missed appointment.
Affirm the patient and reinforce his/her commitment in attending the last visit.
Express your eagerness to see the patient again.
Briefly mention serious concerns that emerged and your appreciation (as appropriate) that the patient is exploring these.
Express your optimism about the patient’s prospects for change.
Reschedule the missed appointment.
If the patient offers no reasonable explanation for missing the appointment (e.g., illness, transportation breakdown), explore with him/her whether missing it might reflect any of the following:
Uncertainty about whether or not treatment is needed (e.g., the patient may state, “I don’t really have that much of a problem”)
Failure to accept the alcohol dependence diagnosis
Frustration or anger about having to participate in treatment (particularly if the patient has been coerced by others into entering the program).
Indicate that it is not surprising, particularly in the beginning phase of treatment, for people to express their reluctance (or frustration, anger, etc.) by not showing up for appointments, being late, and so on. Encouraging the patient to voice these concerns directly may help reduce his/her future missed appointments.
Affirm the patient for being willing to discuss concerns. Then summarize what you have discussed, adding your own optimism about the prospects for positive change, and obtain a recommitment to treatment. Finally, reschedule the appointment.
4.2b. Inactive Status. When a patient misses (unplanned) three or more consecutive scheduled sessions or has not been to a session in a month (whichever comes first), and you have not been able to contact him/her, consider sending a formal note to the patient acknowledging his/her apparent decision not to attend or resume MM treatment sessions and/or take medication. Your note should encourage the patient to return to MM treatment and/or to resume medication at a later time if desired. Urge the patient to have a final evaluation to return unused medications and have a physical exam as a safety check. It is important for safety purposes to have documentation that all attempts were made to conduct a final evaluation on any patient who prematurely discontinues pharmacotherapy.
4.2c. Patients Dissatisfied With Treatment. Patients may report thinking that their treatment is not going to help or may indicate that they want a different treatment. Under these circumstances, you should first reinforce them for being honest about their feelings (e.g., “I’m glad you expressed your concerns to me right away”).
You should also confirm, if asked, that patients have the following rights:
To quit treatment at any time
To seek help elsewhere
To decide to work on the problem on their own.
In any event, you should explore the patient’s feelings further (e.g., “Whatever you decide is up to you, but it might be helpful for us to talk about why you’re concerned”).
4.2c.1. When These Concerns Arise During the First Session. If your patient has these concerns at the first session, he/she is probably worried about a suggested approach he/she has not yet tried. It is appropriate to reassure the patient that you will be offering all the help you can.
You cannot guarantee that any particular treatment will work, but you can encourage the patient to give it a good try for the planned period and see what happens. Add that should the problem continue or worsen, you will discuss other possible approaches and options.
4.2c.2. When These Concerns Arise After Two or Three Sessions. If a patient expresses reservations after two or three sessions, consider whether there have been new developments in his/her life, such as the following:
Have new problems occurred
related or not to drinking?
related or not to the medications?
Is there input or pressure from someone else for a change in approach or for discontinuation of treatment?
Is the patient now aware of problems that he/she ignored in the past by drinking?
Did the Medication Compliance Plan that you developed at the initial visit fail?
Did the patient properly implement it?
Did the patient try it long enough?