The Stick and Rudder Skills of Medication Adherence

My pharmaceutical flight plan starts at my departure airport called the 5 rights (5RTS). I endeavor to choose the right drug, for the right patient, at the right time, the right dose, and the right route. For this flight plan to occur I must choose and recommend the best medication for the patient. The patient is my destination airport (KPTS). 

I spent seven years of pharmaceutical flight training to begin my path of proficiency. Each year, I gathered many important stick and rudder pharmacy skills that I shared and communicated with the patients. My experience, skills, knowledge, continuing education, and research have enriched my role for the education of the patients.

My education began with the basic building block of how medications work in the body. The medication stick and rudder skills are the mechanism of action, the pathophysiology of the patient, pharmacodynamics, pharmacokinetics, and multiple learning methods that can be utilized to teach the patient.

The mechanism of action is how a medication interacts with an organ system and causes an effect. Most medications will cause inhibition, activation, agonism, or antagonism of the cellular or physiological system. For instance, metoprolol succinate (ToprolÒ) is a medication that is called a betablocker. A specific beta receptor is located in the heart called a beta1 receptor. If the receptor is stimulated, an increase in heart rate will occur. You become excited, epinephrine is produced, and the beta1 receptor in the heart is stimulated that causes a high heart rate. A continual high heart rate will not allow the heart’s ventricle to fill completely. Less blood gets pumped to the brain, kidneys, and peripheral vascular system. The prescribing of a beta blocker (metoprolol succinate) will block the beta1 receptor and decrease the heart rate. I teach patients about this effect by a picture and description. “Beta1 receptors live in your 1 heart.”

Pharmacodynamics is what the drug does to the body and pharmacokinetics is what the body does to the drug. If I am speaking to an 85-year-old patient, I know they have a 30-40% decrease in their renal function and they will also have less muscle mass. The patient has a heart rate of 105 beats per minute and their blood pressure is 165/98 mmHg. A beta blocker medication called atenolol is prescribed. My stick and rudder skill of knowing this medication is renally eliminated and knowing the elderly are beta blocker sensitive would have me calling the prescriber recommending a different beta blocker or to decrease the dose. If I did not have this skill and knowledge the patient could accumulate the medication because of decreased renal function. The medication will accumulate and may cause bradycardia (low heart rate) and possibly cause the patient to pass out and fall.

The filing of the pharmacy flight plan is the teaching of the patient. The teaching process is one of the most important steps in medication adherence. The World Health Organization (WHO) in its 2003 report said that if caregivers can increase the effectiveness of adherence methods, there would be a greater impact on health than improving our treatment choices (Sabaté E, ed. Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003). Another very enlightening fact from the report is that approximately 50% of the patient population do not adhere to their medication regimen.

This is my medication education checklist that must done before I speak with the patient. Can the patient afford the medication? Can the patient be compliant with the dosing schedule? Can the patient understand and comprehend and retain the medication education? If I have a choice of 2-3 medications in the same class of drugs, will the patient’s insurance have a reasonable co-pay or is it cheap enough where the patient can afford it on a fixed income?

There are compliance dosing interval differences for a medication given once a day, twice a day, three times a day, or four times a day. The compliance rate for once a day, twice a day, three times a day, and four times a day are 79%, 69%, 65%, and 51% respectively (Osterberg L, Blaschke T. Adherence to medication. N Engl J Med.2005;353(5):487-497). Whenever possible, I always recommend a once a day dose. It is amazing to me to think if a patient is taking a once a day medication that they have an 8 out of 10 chance to consistently take the medication.

Patient medication education and understanding are key to positive outcomes. Many patients have multiple disease states and specialists. Medication reconciliation is a very important process that occurs when a healthcare provider reviews all the patient’s medications for appropriateness. The medication name, dose, frequency, reported side effects, and route (oral, injection, or suppository) are evaluated. I ask the patient to recite to me the names, dose, frequency, and indications of their medication regimen and tell me what their healthcare giver said to expect from the medication. The most common answer is, “I think this for my blood pressure, but I am not sure about the names and dose.”

I begin with a little bit of background on what they do or did for a living. I can then speak and teach in a technical way they can relate to. An important piece of information that must be communicated is how long will the patient be taking the medication. Is this medication going to be taken for a short period of months, years, or for life? Once the education is provided, I ask the patient to repeat back to me, in their words, what they have learned. It is called the teach back method. This is very similar to what my flight instructor did to increase my flying skills. “See one, do one, and teach one.” An important point to this education is not to miss any important information. A study by Tarn et al found that in more than 65% of audiotaped cases, physicians had omitted at least one piece of critical information when discussing starting a new medication with a patient (Tarn DM, Heritage: J, Paterniti DA, Hays RD, Kravitz RL, Wenger NS Arch Intern Med Med. 2006 Sep 25;166(17):1855-62).

Discussing side effects or adverse effects of a medication can be a slippery slope as well for patient compliance. If a patient hears about a side effect that may have a very low probability, they will decide on non-compliance vs. the benefits. This is called rational nonadherence. Patients may start taking a new medication but will decide to stop the medication due to concerns of or presence of a side effect.

My pharmacy stick and rudder fundamentals have been utilized and shared with many patients. I have helped patients stay compliant and informed for better outcomes and quality of life. Each time you see your healthcare provider in the office or via Zoom, go over each of your medications and discuss how you are doing on your medication therapy. Ensure each provider is aware of all medications that are prescribed by other caregivers. You are now qualified and have passed with flying colors your private citizen medication certification. Keep your currency on your medication stick and rudder skills. Stay well, my friends.

Larry M. Diamond, PharmD, CFII

Larry Diamond has a Doctor of Pharmacy Degree and has been a pharmacist for 37 years. Larry’s pharmacy practice has been as a Clinical Pharmacy Specialist in Cardiology, Orthopedic Surgery Specialist and most recently Clinical Pharmacy Coordinator. He is a CFII, a pilot for 33 years and has been an AOPA member since 1984.

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