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The man who forgot to take his medicine

The medication habit starts as a cobweb but should become a cable as quickly as possible. Various factors affect that process, writes retired pharmacist Malcolm E. Brown, of Beccles

By Malcolm E. Brown

The medication habit starts as a cobweb but should become a cable as quickly as possible. Various factors affect that process, writes retired pharmacist Malcolm E. Brown, of Beccles

Taking medicines as prescribed is good for you, like cabbage. But I found it astonishingly difficult to remember to take mine.

My total cholesterol/high density lipoprotein (TC/HDL) ratio was 5.5. That gave a risk of a cardiovascular misfortune of 21 per cent over 10 years: just over the action limit to start a statin.

I inflicted upon my GP an opinion from David Roche (Saga Magazine 2011;[Dec]:94). He urged patients to be wary of which statin they were offered; lipophilic statins such as simvastatin and atorvastatin that crossed the blood/brain barrier had side effects, including dreams.
I hypothesised that headaches might be another (cerebral) side effect. I observed that, after self-prescription with simvastatin, I had suffered severe headaches. They had stopped on terminating that over-the-counter statin, represented on restarting it, then stopped agained when I stopped taking it. My GP was patient with all this — and when I presented a list of statins, including the less lipophilic pravastatin, rosuvastatin and fluvastatin and their costs, he prescribed the more lipophilic atorvastatin, on the understating that, if headache followed, a less lipophilic statin would be offered.

Reasons

Why did I not comply? Fear of headache may be one reason. Another may be that during my professional lifetime my attitude had been to avoid taking non-essential medicines. I had been fortunate seldom to have need for medicines; that long-established habit prevailed over the new logic of taking a statin. Another may be that prophylactic medication did not feel crucial. Omitting a dose did not produce an immediately obvious effect such as pain returning after missing an analgesic.

A habit forms when you routinely perform the same actions. The brain sets up a pathway that is a more efficient way to process the routine. An analogy is ruts in mud. Once they have formed, your car tends to follow them. Forming those neurological ruts takes time. It may take from days to months depending, for example, on how onerous is the habit and whether it is competing with a pre-existing habit.

Old habits die hard. However, much conditioning occurs over a month of daily repetitions; witness a plateau being reached after about 66 days for forming new habits, including eating fruit with lunch (Lally et al, European Journal of Social Psychology 2010;40:998–1009).

How do you form the habit quickly? I asked the Retired Pharmacists Group of our Society how they coped with remembering to take their medicines. I am grateful for their replies; its members provided the following solutions.

Solutions

One strategy is human aid, for example, a spouse (“a guaranteed-to-work reminder device”). That is akin to the important double check during dispensing that reduces errors. The probability of “doer” and “checker” perpetrating the same error on one occasion is the product of the probability of each respective individual making that error. Forgetting to take medicine is an example of an error.

Next is association with some trigger that is already a habit: part of your daily routine. Examples are “taking with your . . . evening bedtime whiskey” or “have my statin on my bedside table and always take a glass of water to the bedroom”. The existing ritual at that time and place is modified; one important special situation is outlined later.

A technical fix is another tactic. Illustrations include an alarm clock, a sticky note or an A4 poster that you see every evening, a virtual sticky note on your computer desktop, an i-Phone application or the calendar in “Outlook”. The notion of reminders for taking medicines, eg, programmed dispensers, has been around since 1915 and perhaps earlier. In 2004 at least 469 patents existed. By July 2012 that had increased to around 4,850 (Espacenet category A61J7/04). One type warns audibly, vibrates and delivers medicines at the prescribed time.

Last is the positive reinforcement of feedback. For example, hearing that my TC/HDL ratio result had fallen to 3.4 encouraged me. Unfortunately that was after a month; the steepest part of the learning curve had passed. Another example is a calendar pack. If the pack is not one of these it “helps to write days of the week on the front or foil back of the blister pack with a marker pen”. It has a “memory” and informs you if you have forgotten to take a dose: the foil remains intact. Unfortunately you are most likely to notice the next day: too late.

You can combine any number of methods; the resulting probability of error will reduce further. Remember the sliced Gruyère cheese analogy: an error only occurs if all the holes fall in a line.

Another approach is, during prescribing, to piggyback new medicines onto a particular trigger: an existing medicine. One retired pharmacist observed: “Simvastatin had to be taken at night as it is short acting and most cholesterol is made by the body at night. Atorvastatin can be taken in the morning as it is long acting.”

Evidence exists for equal effectiveness between morning and evening ingestion. I habitually took — unknown to my GP — a multivitamin/multimineral tablet in the morning. I could have also taken my atorvastatin at the same time.

Habit solidified

But by then I had formed my habit without developing headaches. Night administration did have theoretical advantages, I rationalised. Atorvastatin’s half-life was 14 hours and the rate of cholesterol synthesis was higher at night. Moreover, my blood test evidence applied only to night-time administration. I had solidified my fresh habit: its cobweb had become a cable.

Citation: The Pharmaceutical Journal URI: 11106441

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