Supporting Medication Adherence With Motivational Interviewing

Pharmacists are in a unique position to impact public health, one patient at a time. With more than 90% of Americans living within five miles of a community pharmacy, retail pharmacists often have multiple opportunities for patient engagement, with touchpoints ranging from vaccinations and point-of-care testing to prescription pickups and medication counseling.

Medication therapy management (MTM) is an area in which pharmacists can leverage their trusted role to support better outcomes. Research tells us that pharmacist counseling can improve patient adherence, yet low adherence rates have dogged healthcare for decades. Of the 3.8 billion prescriptions written in the United States per year, approximately 1 in 5 are never filled, and nonadherence costs the health care system between $100 and $300 billion annually.

Pharmacists need more tools in their belt to be as effective as possible in their interactions with patients when it comes to medication adherence. At Biologics by McKesson specialty pharmacy, our clinicians draw from multiple approaches to engage with patients, from conversation starters to risk-assessment questionnaires. One key tool that we are employing now is motivational interviewing—a collaborative conversation style designed to strengthen a person’s own motivation and commitment to change.

What is Motivational Interviewing (MI)?

MI is an evidence-based practice developed by psychologists in the 1980s, originally developed for people with alcohol and substance abuse. Based on the idea that behavior change is possible only when a person feels accepted and valued, MI has been shown to be successful in many different spaces, from smoking cessation and eating disorders to diabetes management.

Research supports the efficacy of MI in promoting medication compliance, including a randomized controlled study of 366 patients with multiple sclerosis, in which the intervention group received telephone counseling based on motivational interviewing.In that study, only 1.2% of patients in the intervention group discontinued the therapy, compared with 8.7% of patients in the standard care group who discontinued treatment.

Any medication-adherence intervention must begin with an understanding that every patient is unique and has different reasons to potentially become nonadherent. Factors impacting adherence can include the patient’s attitudes and beliefs, therapy-related reasons such as adverse effects, and socioeconomic or financial barriers. The beauty of MI is that it acknowledges and makes room for the personal and specific circumstances of every patient.

Guiding Principles and Core Skills of MI

Training in MI is an extensive process for professional counselors, but pharmacists and clinicians can glean insights from its guiding principles and core skills. It starts with understanding what MI is not—confrontational, commanding, preaching, warning, or persuading—and what MI is—nonjudgmental, compassionate, affirmative, open, and accepting.

The guiding principles of MI include:

1. Resisting the righting impulse—that is, avoiding pointing out the risks or problems of a patient’s current (nonadherent) behavior, which can make them defensive.

2. Understanding the patient’s motivations.

3. Listening with empathy.

4. Empowering the patient to find their own motivation to engage in positive behaviors.

Putting these principles into practice, pharmacists can use open-ended questions—“Why are you concerned about your new medication?”—that elicit a response from the patient, rather than questions that feel like a directive or mandate. They can then engage in reflective listening, which involves listening carefully to the patient and repeating back what they say with understanding.

The use of affirmations—“I’m so glad you were able take all doses on time, that’s not easy”—helps to build rapport, demonstrate empathy, and build a patient’s confidence and self-efficacy.

Finally, pharmacists can look out for (and evoke) “change talk” in the patient—“I need to start taking my meds every day” or “I know it’s possible to do this”—and reflect those ideas back to the patient in an affirming and empowering way.

Motivational interviewing is a skill that takes practice, and resources are available to help pharmacists enhance their abilities. The National Community Pharmacists Association offers a 6-module training with 8 hours of continuing education, based on the book Motivational Interviewing for Health Care Professionals: A Sensible Approach by Drs. Bruce A. Berger and William A. Villaume.

At the end of the day, the foundation of adherence is trust, communication, and empathy. Motivational interviewing embraces these concepts to ensure that, ultimately, patients are remaining adherent on their therapy and getting the most benefit from their medications.