by Alan Cassels
Hofling carried out a very interesting hospital-based experiment in 1966, in which hospital nurses were given orders by an unknown doctor to administer a potentially life-threatening dose of a drug to a particular patient. The fake doctor phoned the nurse on night duty and told her to administer 20 mg of “Astroten” – a fake drug – to a patient, promising he would drop by later for the required signature. A bottle of “Astroten” was in the drug cabinet with its label clearly stating that 10 mg was the maximum daily dose.
The result? Twenty-one out of the 22 nurses were prepared to give the patient the Astroten as ordered and actually had to be prevented from doing so during the experiment. Like Milgram’s experiments, Hofling showed that even when people have strong reasons to question authority – such as being asked to deliver a potentially lethal drug– they often won’t question the orders they received. You likely wouldn’t get the same result today, but undoubtedly one stark fact remains: the authority of doctors or specialists over nurses and patients can seem invincible.
While Milgram and Hofling’s experiments have been criticized for cruelly tricking people into following orders, they are incredibly insightful, showing that many of us are hard-wired to not question or disobey authority. After all, “just following orders” is the oldest excuse in the world to explain away bad behaviour, even that of Nazis and those who carried out atrocities on an industrial scale.
In the modern world of pharmaceutical consumption, complying with authority – following a doctor’s prescription, for example – is considered one of the highest duties of a patient. Despite all the new-age assurances around “informed consent” and “doctor-patient collaboration,” we still live in a world where expecting and rewarding obedience endure and thrive.
Patients who are ‘non-adherent’ to their doctors’ orders do so at the risk of souring their good relationship with their GPs. Healthcare professionals understandably expect compliance from patients because they believe that not listening to good medical advice could be risky. Yet in the prescribing world, how big and how bad is this problem?
“Medication non-adherence is truly an epidemic,” according to Mary De Vera, a pharmacoepidemiologist and assistant professor in the Faculty of Pharmaceutical Sciences at UBC. Last summer, she was awarded a university position funded by AbbVie, a major pharmaceutical company.
The “Professorship in Medication Adherence” focuses on, as far as I can tell, the problem of disobedient patients; this is a head scratcher worthy of being filed in the “truth is stranger than fiction” file. What’s clear to me is that Big Pharma’s business model depends on drug sales so they must do their best to squash disobedience. After all, disobedient patients who won’t buy their products are bad for business.
There are certainly times when refusing a prescription may be fatal – getting bitten by a poisonous snake and refusing the antidote or having an asthma attack and refusing a bronchodilator, for example – but the vast majority of prescription drugs don’t fall into that category.
Clearly, not adhering to your doctor’s script is wasteful from an economic point of view. As a patient, if you get a prescription from your doctor, pay for it, but then don’t take it, you’re wasting your doctor’s time and the drug insurer’s and your money. You might also be missing out on something that works to deal with your health complaint.
Dr. De Vera maintains that “non-adherence is a leading cause of preventable morbidity, mortality and cost,” but I would beg to differ. As Peter Gotzsche so colourfully outlines in his book Deadly Medicines and Organized Crime, prescription drugs are the third leading cause of death so how could refusing prescribed drugs be a leading cause of dying or getting sick?
But that’s the line the drug industry and its surrogates like to peddle. One of my colleagues has a good counter to this. He pointed to the arthritis drug Vioxx – likely 150,000 dead after three years on the market – and said, “Nobody died by not taking Vioxx.” How true. Now substitute Prepulsid, Bextra, Baycol, Rezulin (etc.) and dozens of pharmaceuticals removed from the market in the last decade because of their propensity to kill and this ‘medication non-adherence’ crusade seems almost preposterous.
The theme of “non-adherence” isn’t a sentiment that would sit well with the doctors I know because they’ve been raised drinking a different Kool-Aid where “shared decision making” rules. Instead of ‘non-adherence,’ progressive doctors are now talking about “minimally disruptive medicine” and ways to rationalize and reduce peoples’ prescription regimes because they are aware of one indisputable fact: more drugs often lead to more harm.
I looked for research to see if it was harmful to patients if they did not adhere to their prescriptions, but there is very little information available. A recent systematic review by the Cochrane Collaboration found that, even though only about half of all patients take their medication as prescribed, there was scant evidence to show that this made much of a difference. Only five of 180 studies on how to improve “adherence rates” could show any improvements in health outcomes for patients. As the authors noted, “Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.”
While it seems the pharmaceutical industry’s “take-your-meds” approach is working under the 1950s banner of “Father knows best,” a noticeable counter-movement called “de-prescribing” is starting to emerge. Because the problem of excessive medication use in the elderly is becoming more and more known, efforts to ‘deprescribe’ – especially among the overdrugged and frail elderly – are expanding. New educational programs and tools are springing up all over the place to help doctors recognize and act on the problems related to polypharmacy (multiple drug prescriptions) and to try and reduce the potential harm related to all those drugs.
Doctors are starting to recognize that the more drugs you take, the more problems such as drug-to-drug interactions, errors and serious adverse drug reactions you are likely to have. This means – especially in older people – more falls, confusion, delirium and otherwise feeling sicker. One of the biggest reasons many seniors end up in hospitals – and have prolonged stays there – is that they have actually taken the dozens of drugs as prescribed, probably from multiple doctors. As foolish and as crazy as it sounds, many of those drugs were given to deal with the side effects of drugs the patient is already taking!
Even though doctors are starting to work to reduce the risk of polypharmacy, we can all be involved. Here’s one suggestion for seniors and those who care for them. Try taking this line for a test-drive: “Doctor, I don’t want to take all these drugs because they make me feel bad – weak, dizzy, confused, restless, etc. Can you do a trial on me and cut out those drugs that are not essential to keep me alive or which control my symptoms? Can you help me do this?”
No reasonable doctor will refuse this request, if you ask nicely. This is not being disobedient to your doctor’s orders. It’s not about being “non adherent.” It’s about reminding yourself that sometimes you have to be the first one to say, “enough is enough.”
Alan Cassels is a drug policy researcher in Victoria. He is currently working with other researchers in BC and across Canada to develop and test deprescribing tools. Follow him on twitter @akecassels or read his other writings at www.alancassels.com