Look in pretty much any bathroom cupboard and you will find a hoard of half-used or even untouched medicines. Many of us forget to take our pills, or don't finish a course of antibiotics. But we probably weren't that ill. The real surprise is that people taking life-saving medicines do the same. For example, 25 percent of transplant patients don't take their anti-rejection medicines as directed, with some stopping completely.
It is estimated that overall, anything between 30 to 50 percent of prescription medicines are not taken as directed. Usually, patients take them in much reduced doses or intermittently, but 20 percent of medicines never even make it out of the packet. Given that the drugs bill for the UK's state-funded National Health Service (NHS) runs at around ?7 billion a year, the financial cost of non-compliance is an extraordinary waste of money.
But finance is the least of it. Joanna Shaw is director of the Medicines Partnership, an initiative supported by the UK Department of Health which aims to help patients get the most out of their medicines. It has calculated the losses caused by people not taking cholesterol-lowering drugs called statins, as directed.
"For 2003, we estimate that there were 10,000 heart attacks, 5,000 deaths and about 10,000 operations that would have been avoided if those who had been prescribed statins had been taking them," Shaw says.
So why don't people take their medicines? When I began recording Can't Take, Won't Take for BBC Radio, I had an image of someone who doesn't take medicines as older or forgetful. I soon discovered that there is no correlation with age, or, come to that, level of education or gender either. Instead, whether we take our medicines varies from prescription to prescription.
Two elements are at work. Unintentional non-compliance is where we want to take a medicine but are prevented from doing so by barriers beyond our control. It might be that side effects are so immediate or severe that the drug has to be stopped, or something as simple as not being able to get the cap off a bottle or use an inhaler effectively.
Too complex a regime, too messy, too bitter, too hard to break, too big to swallow -- here it is the medicines themselves that defeat people's best intentions. Much work is done by drug companies to improve formulations. For example, a single dose vaginal pessary for thrush has now replaced the gruesome fortnight's worth of messy knicker-staining pessaries that used to be prescribed.
But it's the reasons behind the other element, the intentional non-compliance, that are so fascinating.
"One of the main reasons why people don't take medicines is that they don't want to. They make a decision either not to take it all or to take it in a way that differs from the prescription, which is usually to take less," says Rob Horne, professor of psychology in health care at Brighton University, UK, who is currently completing a major study for the NHS on why people don't take prescribed medicines
"Research has shown that these `to-take or not-to-take' decisions are influenced by two types of belief. First the degree to which we perceive a personal need for the treatment and second how we balance this with concerns about adverse effects," he says.
Many people are suspicious of drugs in general and drug companies in particular. This latter feeling has increased in the past decade, fuelled by media reports of pharmaceutical scandals, such as the link between certain anti-depressants and suicide.
These so called necessity beliefs are closely linked to how people think about their own illness. For instance, if we have a condition which only occasionally makes us ill -- such as asthma -- then it seems common-sense logic that we only need take the medicines when we are ill. In fact this is wrong, but it's entirely understandable.
Julia is an example. She has asthma and has been prescribed a preventive inhaler to use daily, plus a reliever to use if necessary.
"For most of the time I don't feel that I'm asthmatic. Like most people I don't want to take anything that I don't consider necessary," she says.
So she doesn't bother with the preventer, and only uses the reliever when she is wheezy, which is often. She admits that she has come unstuck with this regime. She is wheezing as she relates a chilling tale where a severe asthma attack left her in panic and with blue fingernails, but even this episode hasn't convinced her of the need for her preventer.
She is not alone. About 60 percent of people with asthma do not use their preventer inhalers as directed. Their reasons are similar to Julia's and there are also misplaced fears about the consequences of inhaling steroids, even though the dose is tiny.
And there's another factor at work here. Illness can define us. We have an idea in our minds of what a person with a chronic illness is like and usually it's not us. So even if we do have a chronic condition such as asthma or arthritis, by not taking medicines daily, or in smaller doses, we bolster our perception that we are not that sick person.
Medicines can reinforce our beliefs, both real and imagined. For example the myth that only the old take medicines on a daily basis is a potent one. When middle-aged men are prescribed a daily statin for the first time, many stop taking them. They are not old because they do not take tablets every day. It's a statement akin to suddenly buying a sports car.
And using medicines as a means of rebellion is not confined to paunchy 40-year-olds. In a study of teenage diabetics, Tom MacDonald of the University of Dundee, UK, found that only a third were taking their insulin as directed.
"These kids used to turn up in hospital. Before we discovered they weren't using their insulin, we assumed that they had an unusual form of insulin resistance. One girl confessed to me that she'd found if she didn't take insulin, she could lose weight very quickly," he said.
For some of these adolescents, medicines were a way of controlling and manipulating those around them, despite the consequences being potentially life-threatening.
We are most likely to take medicines properly when their benefits are immediate, and least likely to take them when the condition is silent or a long way down the road. So with antibiotics we take them until we feel better, then we stop. But you would have thought that the consequences of stopping anti-rejection medicines following a transplant would guarantee compliance, so what are the beliefs here that lead so many to stop their medicines?
Perversely, feeling well may be a reason for stopping these drugs, particularly some years after the transplant. The erroneous belief is that the body must now be used to the new organ and that drugs may no longer be necessary in such large quantities.
Another complex reason for cutting down on drugs is those side effects that alter a patient's sense of their own identity such as weight gain with steroids, or hirsutism in women, which add to a sense of not being entirely themselves now they have someone else's organ on board. When you explain people's beliefs, suddenly their decisions don't seem as perverse.
The realization that these beliefs are central to motivations concerning medicines has led to a move away from the paternalistic doctor-knows-best implications of "compliance", towards "concordance", in which doctors have a much more open dialogue about medicines with their patients. But one suspects that this is a problem that is not going to go away -- whatever you call it.
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