Sure, the chemistry of pharmacologic development is fascinating. So are formulation development and production. Marketing pharmaceuticals is exciting, as is the political economy of the drug approval process. But perhaps the most fascinating, important, and entertaining aspect of pharmaceutical science is the oft-ignored issue of whether patients actually take their medications as directed.

The development of pharmaceutical products requires the development of a molecule that acts at some target to achieve benefit. It also requires placing the active molecule in a formulation capable of delivering the drug. In addition, in the clinic, physicians need to make the right diagnoses and need to prescribe the right treatment. But pharmacologic development and clinical application are just two legs of a three-legged stool. The third, absolutely essential element to successful drug treatment, whether viewed by the pharmacologist or the physician, is getting patients to take the medication.

Adherence (or compliance or concordance or whatever other term you prefer to use) is of importance to patients, to their families, to their doctors, to their insurers, and to the companies that make the products that would improve these patients’ lives, if only the patient would take the drug.

And there’s the rub. Too many patients don’t take the drug as prescribed. They may never start on the drug. If they do start, they may not take it as often as prescribed. They may double up on the dose, or more, which can be very risky, depending on the drug product. Patients may stop taking their medication entirely, which certainly isn’t good for the outcome of chronic treatment or for pharmaceutical sales numbers.

Adherence has many dimensions; the various ways patients can be non-adherent and the many stakeholders with an interest in patients taking their medicines are but a few. But perhaps what makes adherence so complex and interesting are the many, many ways in which adherence behaviors are influenced by psychological, social, and economic factors; by internal and external influences; by the efforts of insurers, drug companies, and doctors; and by patients’ friends and relatives.

It’s now time to go past the usual patient education and reminder thinking that has been pervasive. It’s time to take a more comprehensive, 360-degree look at all the various parameters of and influences on people’s psychology and behavior—and at the resulting targets of which pharmaceutical marketers can take advantage.

My field of expertise—dermatology—is a fabulous model laboratory for understanding poor adherence behavior. We know patients don’t take their pills. Imagine how much worse adherence is to the messy, greasy preparations I ask patients to apply to their rashes. For the first 10 years of my clinical practice, I paid little to no attention to adherence issues. I believed in the dogma of my specialty, that medications gradually lose effectiveness as patients become resistant to the effect of the medicine. And I had lots of patients who responded poorly to therapy.

The next 10 years were completely different. Having become aware of the problem of poor adherence, I now spend nearly all my patient-care time thinking about adherence. (“All” would be an exaggeration. It does take a few moments to diagnose skin conditions and to determine the appropriate pharmaceutical intervention.) I’ve come to realize that medications gradually lose effectiveness because patients gradually stop using them. And now I have countless patients who achieved what they would call “miraculous” results from treatments that had previously “failed.”

In the articles that follow in this series, I will share the techniques for achieving “black belt” status in the martial art of adherence manipulation.

  • Steven Feldman, M.D.

    Dr. Steven Feldman is Professor of Dermatology and Public Health Sciences at Wake Forest Baptist Medical Center. Steve studies patient adherence at North Carolina’s Wake Forest Baptist Medical Center. He is also Chief Science Officer of Causa Reseach, an adherence solutions company (, founder of, and author of “Compartments” and “An Illustrated Dictionary of Behavioral Economics for Healthcare Professionals.”