Brent I. Fox, Pharm.D., Ph.D., is an associate professor in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University
Brent I. Fox, Pharm.D., Ph.D.
Joshua C. Hollingsworth, Pharm.D, Ph.D.

“DRUGS DON’T WORK IN patients who don’t take them,” as former U.S. Surgeon General C. Everett Koop, M.D., famously said. Medication adherence — the extent to which a patient takes medication as prescribed — is requisite for their therapeutic effects to be fully realized, including the minimization of disease progression and the risk of major sequelae. For instance, adherence to antihypertensive medications that properly manage blood pressure can decrease the risk of heart failure, coronary heart disease, stroke, peripheral arterial disease, and renal disease. Since most medications are given in oral form, such as pills, capsules, etc., and are dosed only once or twice daily, one may think that adherence would be a nonissue. But as pharmacists and pharmacy technicians, we know that this could not be further from the truth. It is estimated that three out of four Americans are nonadherent to their prescribed medications, and adherence generally decreases as the pill burden, or number of prescribed medications, increases. Medication nonadherence greatly increases mortality and healthcare costs. In the United States, it is estimated that about 125,000 deaths and $100 billion to $289 billion in medical costs per year are directly linked to medication nonadherence.

There are several approaches available that are meant to address medication adherence, all with varying degrees of evidence as to their effectiveness. Some approaches are low-tech. Others are bleeding-edge technology. The approach chosen depends greatly on the patient, his or her perceived barriers, and the medication. Seeing as this is a column about technology, we’ll start with the high-tech approaches and work our way down.

Digital pills. A digital pill is a medication embedded with a sensor that transmits adherence data (i.e., if and when the medication was taken) through a patch worn by the patient to a mobile app. Patients can use the app to access the data themselves.
They can also allow caregivers and healthcare providers access to the information through a web-based portal. We discussed digital pills in the previous installment of this column, including the first digital pill, Abilify MyCite, which was approved by the FDA in November of 2017. Something we did not mention is that, according to the drug’s labeling, its ability to improve medication adherence has not been shown. Still, one can easily see the value in such a system. And, specific to antihypertensive medications and blood pressure management, there is evidence of benefit when the adherence data from digital pills is shared with pharmacists. In a small study by Kevin Noble and colleagues, that was published in the Journal of the American Pharmacists Association in 2016, they found that such a system helped them identify and subsequently counsel those patients who were not achieving adequate blood pressure control due to nonadherence. As more digital pills come to market, we expect to see more robust studies exploring their effect on medication adherence.

Smart pill bottles. Smart pill bottles incorporate sensors, either in the bottle or the lid, that record actions related to the bottle itself (such as removal of the lid) and timestamp each time an action is taken. In the case of smart pill bottles that record the lid being removed, each opening and closing serves as a surrogate marker for medication administration. Smart pill bottles are commonly used in research to simply track medication adherence. However, since they can provide medication alerts and reminders, and their data can be shared with healthcare providers and caregivers, smart pill bottles can also be used in efforts to enhance medication adherence. Available products include Medication Event Monitoring System (MEMS) Caps, AdhereTech, and Pillsy, among others. Similar to digital pills, smart pill bottle systems can be used to identify and subsequently counsel nonadherent patients. Unlike digital pills, these systems can be used with any medication dispensed in a vial.

Mobile apps. Yes, there’s an app for that. In fact, according to a 2015 study by the University of Arkansas for Medical Sciences, there are over 450 medication adherence apps. And this number has surely increased since 2015. These medication adherence apps offer varying functionality, such as scheduled reminders, drug interaction warnings, refill alerts, health marker tracking (e.g., blood glucose, blood pressure, etc.), and sharing of data with caregivers and healthcare providers. The aforementioned study identified the following free apps as being the most trustworthy: Mango Health, MyMeds Medication Management, MediSafe Meds and Pills Reminder, and Dosecast Medication Reminder. Mobile apps such as these can be used by patients to improve their medication adherence.

Text messaging. We covered the use of text messaging in pharmacy in a previous installment of this column. When used alone, scheduled text messages can be used to remind patients to take their medications at the appropriate time. This approach has been shown to significantly improve medication adherence, at least in the short term. Text messaging could also be combined with digital pills or smart pill bottles,
allowing an approach that targets medication nonadherence as it occurs. Given that nearly every adult now has a mobile phone, text messaging is a wide-reaching and relatively inexpensive approach to enhancing adherence.

Pillboxes. Although they are low-tech or no-tech, inexpensive and easy-to-use pillbox organizers may improve medication adherence. Pillboxes are useful for presorting medications into separate sections for days of the week and times of day. This sorting can be done by a caregiver, a healthcare provider, or patients themselves. Pillboxes simplify matters when it comes time to actually take the medication. Pillboxes are especially useful for forgetful patients, as they can verify whether they have taken their medication for the day by visually inspecting their pillbox. Medicine-On-Time is a similar and effective solution, with the added benefit of having the filling pharmacy prepackage complex medication regimens into calendar cards. The calendar cards resemble pillboxes that are clearly labeled and color-coded to indicate the time of day that the medication should be taken. In addition to low-tech pillboxes, smart pillboxes are also available. They function very similarly to smart pill bottles and can be used to remind patients when and how to take their medications, monitor when the medication is taken, and generate dashboards and reports that can be shared with caregivers and healthcare providers.

Patient counseling. Although there is no technology involved, we would be remiss if we did not mention the importance and power of a pharmacist talking to his or her patient when it comes to medication adherence. In order for patients to take a medication appropriately, they must be fully informed as to what this entails. It is common for patients to stop taking a medication because they feel that it is no longer necessary or that it is not working. Thus, informing patients as to expectations in terms of duration of therapy and signs of effectiveness is very important. Addressing patient-specific barriers is also crucial. Forgetfulness is a top-cited barrier for many patients. To address this, help patients identify appropriate context cues that can be used to remind them to take their medication. For instance, if the medication is to be taken every morning, and your patient drinks coffee every morning, then mentally anchoring the taking of the medication to drinking his or her morning coffee can be helpful. Further, the medication can be kept near the coffee so that it will be seen when the coffee is being prepared. Other common barriers to consider include costs and adverse effects or fear thereof.

Here we have covered several approaches that can be used to improve medication adherence. Some, such as digital pills, digital pill bottles, and text messaging, are generally driven more by healthcare providers, while others, such as the use of pillboxes and mobile apps, can be driven by patients, providers, or both. No matter the approach used, patient counseling is crucial to setting expectations and addressing barriers. What approaches do you take when working with patients to address medication adherence? Let us know. We welcome your comments and questions. CT

Joshua C. Hollingsworth, Pharm.D, Ph.D., is an assistant professor, Pharmacology and Biomedical Sciences, Edward Via College of Osteopathic Medicine, Auburn University and Brent I. Fox, Pharm.D., Ph.D., is an associate professor in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy.The authors can be reached at and