ReviewThe use of incentives to reinforce medication adherence
Highlights
► Incentives for medication adherence are promising but understudied. ► Available evidence suggests these interventions can be very effective. ► Sustainability and scalability are key challenges for future interventions.
Introduction
The success of any pharmacotherapy depends critically on adherence to the prescribed medication regimen. Many treatments for chronic conditions and diseases require daily action on the part of the patient for the entirety of their lives, and even single-dose treatments require patient participation. Failure to adhere to a pharmacotherapy can have catastrophic effects for the patients, which in turn leads to greater cost of care. Increases in hospital admissions due to poor medication adherence cost an estimated $100 billion/year in the United States alone (Osterberg and Blaschke, 2005). The problem is widespread, and the World Health Organization (Sabaté, 2003) estimates that in developed nations only 50% of patients with chronic conditions adhere to (i.e., take at least 80% of) their prescribed medicines. The potentially severe health consequences and the enormous economic burden of medication non-adherence make the development of highly effective means to improve medication adherence a top priority for behavioral science.
Several high-profile reviews have concluded that there is an urgent need to develop effective interventions for medication adherence, that no single method or type of intervention is detectably superior to all other interventions, and that the best interventions evaluated to date have produced only small to moderate effects (Cutler and Everett, 2010, Kripalani et al., 2007, McDonald et al., 2002, Osterberg and Blaschke, 2005). A similar conclusion was drawn in a Cochrane review on the topic (Haynes et al., 2008), which also noted that a taxonomy of the interventions attempted thus far was not feasible because of the complexity and multi-component nature of most of the interventions that have been evaluated.
The principles of operant conditioning are the basis for many highly effective behavioral interventions. These interventions emphasize the importance of targeting specific, observable, and measurable behavior, and as such may be especially well suited as a means of improving medication adherence. Perhaps the most common kind of operant intervention is the reinforcement procedure, in which the availability of an incentive is contingent upon the occurrence of a target behavior. Such interventions are effective in the treatment of drug addiction (Higgins et al., 2008, Lussier et al., 2006), in improving the lives of individuals with developmental disabilities and autism (Fisher et al., 2011), and in improving safety and productivity in the workplace (Austin and Carr, 2000), among other applications. These kinds of interventions can also promote medication adherence, though attempts to address medication adherence via patient incentive programs have been relatively uncommon. The purpose of the present review is to describe the literature on the use of incentives as applied to the problem of medication adherence. A review of the relevant principles and procedures of operant conditioning is beyond the scope of the present review, but interested individuals should consult a comprehensive text (e.g., Cooper, Heron, & Heward, 2007).
Section snippets
Methods
Studies were identified by searching the electronic databases MEDLINE, PsycInfo, and Academic Search Complete. The search engine employed SmartText searching. The following search terms were combined using Boolean operators OR or AND as appropriate: Drug, Medication, Adherence, Compliance, Incentives, Reinforcement, Contingency, and Intervention. Searches were limited to peer-reviewed articles, but no other restrictions were applied. Relevant articles, including reviews, were hand-searched for
Naltrexone
Naltrexone is an opiate antagonist that blocks the physiological and reinforcing of opioids (Martin et al., 1973, Mello et al., 1981). Naltrexone’s lack of abuse potential and overall safety (Schecter et al., 1974) make it pharmacologically ideal for the treatment of opioid dependence. However, adherence to naltrexone has been very poor and as a result it is rarely prescribed (Kosten and Kleber, 1984).
Naltrexone pharmacotherapy for opioid dependence may be an especially difficult target for
Discussion
Incentive-based medication adherence interventions are promising but understudied. Studies that are well controlled or that feature large sample sizes are rare and no single study offers both of these features. Overall, the studies that include at least moderate value incentives (i.e., >$100/month) suggest that incentives confer substantial benefit in increasing medication adherence. In studies where the base rate adherence was moderate (e.g., Sorensen et al., 2007), incentives increased
Conclusions
Incentive-based medication adherence interventions can effectively promote medication adherence under a variety of conditions. A significant challenge for research in this area is the development of sustainable and cost-effective long-term interventions.
Conflict of interest statement
The authors declare no conflict of interest.
References (62)
- et al.
Effect of incentives for medication adherence on health care use and costs in methadone patients with HIV
Drug Alcohol Depend.
(2009) - et al.
Contingency management of adherence to a complex medical regimen in an elderly heart patient
Behav. Ther.
(1979) - et al.
Employment-based reinforcement of adherence to an FDA approved extended release formulation of naltrexone in opioid-dependent adults: a randomized controlled trial
Drug Alcohol Depend.
(2012) - et al.
Compliance with tuberculosis treatment in methadone-maintained patients: behavioral interventions
J. Subst. Abuse Treat.
(1993) - et al.
Behavioral treatment of cocaine-dependent pregnant women and TB-exposed patients
Addict. Behav.
(1995) - et al.
Improvement in naltrexone treatment compliance with contingency management
Drug Alcohol Depend.
(1999) - et al.
Voucher reinforcement improves medication adherence in HIV-positive methadone patients: a randomized trial
Drug Alcohol Depend.
(2007) Targeted tuberculin testing and treatment of latent tuberculosis infection
MMWR Recomm. Rep.
(2000)- et al.
Managing very poor adherence to medication in children and adolescents: an inpatient intervention
Clin. Child Psychol. Psychiatry
(1999)