Motivational Interviewing Offers a Path to Improved Adherence

As the scope of pharmacy services shifts toward a greater emphasis on direct patient care,¹ the Accreditation Council for Pharmacy Education and the American Association of Colleges of Pharmacy stress motivational interviewing as an essential skill for pharmacists and the delivery of pharmaceutical care.

“The way we talk to patients has not changed appreciably in 40 years. We’re still using parental ways of talking to patients and giving information as if information itself will solve the problem,” said Bruce A. Berger, PhD, president of Berger Consulting, LLC, and professor emeritus at Auburn University in Alabama. “If information were enough, why would any health care professional smoke or be overweight?”

Unfortunately, nearly 75% of adults are nonadherent in 1 or more ways, such as not filling a new prescription or taking less than a physician-recommended dose.² Poor adherence can lead to worsening conditions, especially for those with chronic conditions.

This is why clinicians must not only identify nonadherent patients but also facilitate discussions with them to identify barriers to adherence. Specifically, pharmacists and pharmacy technicians can play a valuable role here because nonadherence may not be the result of a pharmacologic manifestation, such as adverse effects or drug interactions, and it may not be the result of patient ambivalence.

“Many times, [managing] nonadherence may be as simple as addressing affordability by finding patient assistance programs or other social programs aimed at helping patients financially,” said Jeremy Sasser, pharmacy content strategist at the National Healthcareer Association.

“Other times, providing different packaging options or recommending various compliance aids to help remind patients when to take their next dose can improve adherence,” he said. “Enrolling them in medication synchronization and auto-refill programs may also help with maintenance medications.”

MOTIVATIONAL INTERVIEWING

Motivational interviewing is an individual-centered, collaborative approach designed to elicit and explore the patient’s own reasons for change within an atmosphere of acceptance and compassion. It can strengthen an individual’s own commitment and motivation to make healthier, adaptive changes, especially behavioral and lifestyle ones.

Motivational interviewing:

• Better uses opportunities to discuss patients’ health-related behaviors, such as alcohol use, diet, exercise, self-management of health problems, and smoking
• Builds patients’ intrinsic motivation to adopt and maintain treatment recommendations
• Encourages patients to express their own reasons for concern with their lifestyle behaviors or their prescribed treatment regimens
• Helps resolve patients’ ambivalence about behavioral change and strengthens their ability to take responsibility
• Shifts the discussion to a patient-centered interaction, rather than a disease-focused one
• Systematically explores the ambivalence associated with a behavior

Berger’s expertise is in interpersonal and organizational communication and psychology, as well as the application of these disciplines to the pharmacist’s role in treatment adherence and outcomes. When individuals are ambivalent or resistant, their decision making is impaired by inaccurate or missing information, Berger said. However, he added, when their health care providers ask open-ended questions to get an understanding of where they are coming from, practitioners stand to gain trust. This trust, combined with information, is more powerful than information alone.

“When you create faith loss in a patient, they discount the information you give them, or they stop listening,” Berger said. “We scold patients for the things they are not doing rather than finding out why they are choosing not to do some of the behaviors we request.”

Motivational interviewing can help providers find that why, and if skillfully used, motivational interviewing can contribute to a much stronger therapeutic alliance by:

• Encouraging patients to fully participate in decisions affecting their health
• Increasing a patient’s engagement in treatment and explicitly acknowledging and addressing ways to resolve ambivalence
• Nonjudgmentally opening the conversation to consider personal preferences and values, even if those are at cross-purposes with the “evidence”
• Reducing the potential for nonadherence and encouraging behavioral change to achieve better outcomes

“Patients visit their pharmacy much more often per year than they visit their medical provider. Pharmacy technicians are often their first and last point of contact and, occasionally, the only point of contact,” Sasser said.

Arming pharmacists and techs with the skills to build rapport and trust with patients allows them to more skillfully extract pertinent information and uncover concerns that can help with overall adherence rates. Indeed, motivational interviewing is seeing positive results. In 1 study led by Berger, patients with multiple sclerosis who received motivational interviewing techniques via software-based telephone conferencing demonstrated a statistically significantly lower proportion of Avonex treatment (1.2%) discontinuation than the standard-care group (8.7%). In addition, stage movement away from discontinuation of Avonex (ie, toward continuation of therapy) was significantly higher in the treatment group.³

A patient’s capacity for self-management is fundamental to his or her ability to adhere to a treatment plan. Prescription medications are an essential component of treatment. But if prescription drugs are to fully realize their potential benefit and deliver improved health outcomes, practitioners need better methods of ensuring that patients have the ability and support they need to follow the drug regimen in their treatment plan. Motivational interviewing is a path toward improved self-management that, when used effectively in pharmacies, can help improve adherence and lead to better long-term outcomes for patients.

Jessica Langley is the executive director for education and advocacy at the National Healthcareer Association in Leawood, Kansas.

REFERENCES

• National Governors Association. The expanding role of pharmacists in a transformed health care system. classic.nga.org/files/live/sites/NGA/files/pdf/2015/1501TheExpandingRoleOfPharmacists.pdf. Accessed July 3, 2019.
• Take as directed: a prescription not followed [news release]. Alexandria, VA: National Community Pharmacists Association; December 15, 2006. ncpanet.org/pdf/adherence/patientadherence-pr1206.pdf. Accessed July 3, 2019.
• Berger BA, Liang H, Hudmon KS. Evaluation of software-based telephone counseling to enhance medication persistency among patients with multiple sclerosis. J Am Pharm Assoc (2003). 2005;45(4):466-472.