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."
By Peter Slavin, Special to NASW News
|Illustration: John Michael
Today, it's hard to overstate the importance of following instructions
about medicines in a society where taking pills is a daily event
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,
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
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
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
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
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 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
"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: www.socialworkers.org/practice/aging/aging0304.pdf
From June 2004 NASW News. © 2004 National
Association of Social Workers. All Rights Reserved. NASW News
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