Deborah Willhite, who helped formulate the U.S. Postal Service's response to last fall's anthrax attacks, stopped taking her antibiotics a full two weeks before her 60-day prescription ended.
Willhite, an agency senior vice president deemed at risk for anthrax exposure, couldn't stand the vomiting, an occasional side effect of the medication. The last straw was throwing up in a store parking lot while she was loading packages into her car.
"I heard a couple rolling by me with a shopping cart saying, 'Isn't that the lady with the Postal Service that's on TV all the time?' " she recalled in an interview. "That was the last day I took doxycycline."
Willhite acknowledges that she should have been a role model for medication compliance. But instead she acted like many American patients, whether they face anthrax, angina or asthma: She took prescription drugs when and how she saw fit.
"I didn't set a very sterling example, I'm afraid," Willhite said.
Actually, she was among the more compliant of the 10,000 people at highest risk for anthrax exposure in Florida, New York, New Jersey and Washington, D.C.
In New York City, for example, health officials say as many as half of those prescribed anthrax antibiotics never took a single dose--even though the disease had proved rapidly deadly and the drugs were free. Even in Washington, where nearly everyone began their drugs, only 60% of people surveyed said they had taken the drugs every day for 30 days.
"If your co-worker died of the disease and you know that there are spores in your environment . . . and you still don't take the medication, imagine how much of a bigger problem we have for things that are less in your face, like your blood pressure and your cholesterol," said Dr. Jerome Avorn, an associate professor of medicine at Harvard Medical School.
Research has shown that the problem extends far and wide--to patients who are on the verge of blindness from glaucoma and those who have just undergone life-saving kidney transplants. Even women trying to prevent pregnancies routinely miss one or two doses of their birth-control pills each month.
Overall, about 50% of people don't take medications for chronic conditions as ordered by doctors. It's "a dirty little secret in health care," said Avorn, who has written extensively about the issue.
The reasons patients cite for stopping--or never starting--medications are varied. Some feel fine without the drugs. Some simply forget. Others don't have money or insurance, or the side effects are too much to bear.
And then there are many people who foul up the timing of their drug treatment--and then try to compensate for skipped doses by taking more.
Compliance is particularly important with antibiotics, which work by attacking bacterial cells within the body and preventing their ability to reproduce. If the drugs are taken inappropriately, they kill only some of the bacteria, allowing remaining cells to thrive and develop resistance to those antibiotics in the future.
Completing a prescription generally kills off all bad bacteria, removing those risks.
Studies Show Patients Lie to Their Doctors
Doctors often take for granted that patients will take their drugs as prescribed, but researchers have shown conclusively that such assumptions often are wrong.
In one 1986 study, for instance, researchers placed an electronic device in the eye droppers used by glaucoma victims. It tracked every time the bottle was opened and turned upside down. On average, people missed about a quarter of their prescribed doses. But in interviews, patients said they had taken a full 97% of their drops.
Other studies have similarly shown that people lie about their habits to stay in their doctors' good graces. In the day or two leading up to a doctor's visit, patients tend to take their medications more religiously, an effect some researchers have called "white coat compliance."
When he was a young eye surgeon, Dr. Kenneth J. Hoffer of Santa Monica said, "I just assumed that glaucoma patients would [follow directions] just out of the fear of losing their sight. . . . [But] as time went by, sometimes I would find that patients were lying to me."
Initially, he said, most did try to follow directions. When it became a bother, however, patients seemed to build up "a resentment about it," and many rebelled.
When patients stray, studies show, some get sicker faster and die earlier. And taking the drugs haphazardly can lead to more health problems than not taking them at all.
Sensing a market, entrepreneurs have devised techniques and gadgets to keep patients diligent. Some companies sell pillboxes with beeping alarms, refrigerator magnets that blink, watches that vibrate, and subscription reminder services for pagers and cell phones.