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Teamwork Key in Managing Medication

Social Workers' Role Vital in Promoting Adherence

Not adhering to prescription regimens has been called "the nation's other drug problem."

Today, it's hard to overstate the importance of following instructions about medicines in a society where taking pills is a daily event for millions.

In this culture, "medication is the main way medicine is practiced," observes Maura Conry, a clinical social worker and clinical pharmacist who is psychiatric clinical coordinator at Shawnee Mission Medical Center in Kansas City, Kan. But many people seem to have an innate reluctance to take drugs of any kind, and how to get individuals to take their medicines regularly and safely has long perplexed clinicians.

Social workers address problems of adherence at every turn, and not only those who are employed in health care or mental health settings. Take the school social worker counseling a child with diabetes reluctant to take insulin, or the social worker at a homeless shelter working with a resident with high blood pressure, or the private practitioner treating a client who is abusing prescription drugs, or the psychotherapist working with a person living with AIDS who is having trouble sticking to the painstaking regimen for antiretroviral drugs.

Conry finds it hard to think of a social work venue free of adherence issues, whether the drugs be psychotropic or antibiotics, prescription or over the counter.

The scale of the problem is easily illustrated: According to Kia Bentley, professor and director of the Ph.D. program in social work at Virginia Commonwealth University, a study found that among people with high blood pressure, only one-third took their medication as prescribed, another third took little or no medication, and a third were intermittently adherent.

High stakes. The stakes could hardly be higher. The powerful drugs for chronic diseases on the market today can have blessed effects if taken as directed, says Conry. But if they're not, they can put people in the hospital or worse. According to NASW's March 2004 Aging Practice Update "Medication Adherence and Older Adults," 10 percent of all hospital admissions and 23 percent of nursing home admissions stem from medication nonadherence, and nonadherence accounts for 125,000 cardiovascular deaths annually.

Nonadherence, Conry says, is especially dangerous for those with mental illness, because without medication they relapse rapidly. Adherence is also extremely important for HIV patients, because antiretroviral therapy regimens "are very demanding and unforgiving," says Lisa Cox, associate professor of social work at The Richard Stockton College of New Jersey. Missing even a few doses, Cox adds, can lead to the virus becoming drug resistant and possible treatment failure. For older Americans, those most reliant on medicine, adherence "represents a critical care issue, sometimes referred to as the 'the nation's other drug problem,'" the NASW Aging Practice Update states.

The reasons why clients miss taking medication make up a long list, but there is an unfortunate tendency toward simplistic thinking on the subject, says Kia Bentley. She says people tend to come up with naive explanations, such as "Oh, Sally didn't take her medication because she's in denial."

Bentley, who wrote the book The Social Worker and Psychotropic Medication with Joseph W. Walsh, says it is better to think in terms of risk factors for nonadherence and protective factors for adherence. Risk factors include such things as adverse side effects, forgetfulness, a history of substance abuse and an unfriendly aftercare setting. Among the protective factors are acknowledgment that one has an illness, adequate education about the medication, and affordability.

Social workers' role. Observers agree that social workers have a vital part to play in promoting adherence. For one thing, in this era of managed care, they have more time to spend with patients than doctors or nurses have. For another, unlike doctors and nurses who generally stay in their facilities, social workers are out in the community, engaged with caregivers and families. They are closer to patients and engage them on levels beyond the medical.

There are numerous strategies social workers can use to promote adherence. Bentley recites some: "I can provide education. I can provide behavioral intervention. I can talk with you about the meaning of medication. I can work with your family. I can work with your physician around adjustment. I can teach you to talk to him or her about your medication."

A major role for social workers is communicating with and educating patients. This means not only explaining why they need the medication and how best to take it, but also dealing with certain beliefs and fears that deter people from following prescriptions. When it comes to pain medication, for example, says Yvette Colon, director of education at the American Pain Foundation, these ideas include a fear of addiction and of terrible side effects and the notion that the pills should be saved in case the pain grows severe.

NASW Executive Director Elizabeth J. Clark, a former hospital social worker, sheds light on this last notion. "The most important thing in pain control is getting a level of pain medicine in your system and keeping it steady," she says. "Most people don't understand that, so they don't take their pain medicines until they're in pain, they don't take them routinely. . . . They haven't been educated about how they're most effective."

Some social workers even provide clients with written medication schedules and pictures as well as alarm clocks and daily or weekly pillboxes. Another idea is to tie the regimen to a TV program the patient watches regularly.

In addition, social workers monitor the effects of medication, detect problems and work with the health care team. Social workers can also teach patients to advocate for themselves should the medication or dosage no longer be effective. And social workers can develop adherence support groups or add adherence issues to the agendas of existing groups.

On another front, they can offer support to the patient and caregiver for example, helping them cope when a change in functioning causes an inability to work or when the drug's price becomes an issue.

In fact, community health care teams working in the area of infectious diseases have started hiring social workers and others as adherence managers to help HIV/AIDS clients. NASW's HIV/AIDS Spectrum Project has trained social workers in understanding the role of social work in medication treatment adherence, using HIV/AIDS as a case study [March News].

Ethical issues. Bentley stresses the ethical issues surrounding adherence. She points to the line between coercing and encouraging clients. "We should not be on the sidelines screaming 'Rah-rah meds, rah-rah meds,'" she says. "Nor should we be on the sidelines pooh-poohing meds."

"Our role," she adds, "is to help people make informed decisions, share what research shows and doesn't show . . . what the experience of our clients has been [when] medications have been life-changing and life-altering as well as . . . [when] it hasn't been as helpful as they want."

Most of all, she tells her students, "Don't care less about a client because they make a decision you disagree with" about taking medication. "You are with them in those trenches no matter what."

Beyond adherence. Clark points out that social workers play a much broader role in medication management than just promoting adherence, though other professionals don't always realize this. Social workers make assessments of clients, including what medications they are taking. They identify and counsel clients who are abusing medication. They help clients negotiate treatment plans they can accept. They advocate adequate pain control for clients whose pain is overlooked. They provide cognitive-behavioral therapy for pain. They advocate healthy grieving rather than a rush to tranquilizers. They serve as the intermediary between patient and physician and sometimes are the patient's advocate. They find government-subsidized medications for clients who have run out of funds.

Collaboration. Conry warns that social workers heavily involved in adherence issues should collaborate with medical professionals to ensure patients' safety for example, by catching the prescribing of incompatible medications. She urges social workers to develop relationships with pharmacists they can consult for scientific explanations of drugs and for advice. When a medication problem occurs, she says, most social workers call the doctor, when in fact a pharmacist is far easier to reach.

Conry also advises social workers to help clients understand the benefits of using one pharmacy for all their prescriptions. That way, the pharmacy has a record of all of them in its computer and can run a cross-check on them to ensure compatibility. If, however, a client is using several pharmacies, Conry recommends a "brownbag consultation" gathering up all of the medications in a grocery bag and taking them to a friendly pharmacist for evaluation.

Beyond informal alliances, Conry advocates that social workers and pharmacists form teams to help elderly and chronically ill clients in the pharmacy's neighborhood with adherence issues, including the accidental misuse of medications. Pharmacists are legally required to educate and counsel customers about medication, she notes.

She sees the two professions as complementary. Pharmacists know the clinical and precise biomedical side of drugs, and social workers are experts in human motivation. Also, a pharmacist only sees the client for a few minutes now and then, and a social worker has more opportunity to observe medication-induced changes in the client.

"My team would actually be a triad of the pharmacist, social worker and patient," Conry says, "with the patient the most important member of the triad, because it's their life." The team would create a care plan with the patient. The pharmacist and social worker would then collaborate on medication case management, with the social worker responsible for overall care management.

For NASW's Aging Practice Update:

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