Tackling the 3 Leading Causes of Nonadherence: Fear, Cost, and Misunderstanding

Medication nonadherence costs the U.S. pharmaceutical industry an estimated $250 billion annually in potential revenue. It’s time brand teams took a fresh look at the reasons for nonadherence and what they can do to prevent it. Let’s start with a brief review of the causes of this gigantic problem, then look at some emerging solutions.

Causes of Nonadherence

Medical literature is bursting with excellent reports addressing nonadherence.1-3 One of the best recent publications is a 2023 paper by Stewart, Moon, and Horne,4 which notes that nearly 800 individual factors are associated with medication-taking behavior. Some causes are outside of pharma’s influence (e.g., insurance coverage, patient age, patient culture), while others are within it (e.g., patient out-of-pocket (OOP) cost, lack of education). The authors emphasize the importance of focusing on these modifiable causes.

The American Medical Association (AMA) takes a simpler approach. In its brief “8 Reasons Patient Don’t Take Their Medications,”5 they list these key causes of nonadherence: fear of side effects, cost, misunderstanding, too many medications, lack of symptoms, mistrust, worry, and depression. We’ll focus on the three top-listed causes: fear of side effects, cost, and misunderstanding.

Which Nonadherence Causes Can Pharma Address, and How?

Before jumping into solutions, let’s make it clear that drug manufacturers have not had their heads in the sand regarding nonadherence. On the contrary, brand teams typically manage their brands based on well-developed customer relationship management (CRM) “patient journeys” that are supported by a series of direct-to-patient emails, Short Messaging Service (SMS) messages (aka text messages), direct mailers, or advocacy group connections. These touchpoints are designed to help patients stay current on adherence issues such as side effects management, the importance of staying on therapy, or a simple confirmation that patients are not alone on the path to health. And, of course, most brands provide robust copay support. Sadly, those baseline efforts are often not enough to counteract the pull toward nonadherence.

Fortunately, brand teams aren’t working alone. An array of service providers, each with established point-of-care expertise, is available to help marketers build out a full omnichannel approach to support patient adherence. The truth is that while pharma marketers and their service partners may not be able to help in every area of nonadherence, they can certainly help on some.

Now, let’s get back to those three leading causes of nonadherence and identify some of the novel messaging solutions that can help patients stay on therapy.

Fear of Side Effects

Thinking like a patient, we understand the fear of side effects mentioned in commercials or called out in online posts. Patients need to weigh the pros and cons of taking medications that could have serious side effects. The key for brand teams is to communicate with patients so they understand what side effects to expect, how long they might last, and how to deal with them successfully to stay on drug. Fortunately, you can reach patients with these supportive messages in several tech-based ways:

  • New technology can send side-effect-focused messages to patients while they are in the HCP office via print, text, or patient portal. The appropriate message—based on the National Drug Code (NDC) and/or other triggering criteria—is generated when a prescriber creates an electronic prescription (eRx) during a medical encounter. This technology has been proven to educate patients and mitigate Rx abandonment.
  • Brands can use SMS messaging to reach opted-in patients, proactively addressing key side-effects issues. Multimedia Messaging Service (MMS) enables creation of even richer engagement touchpoints, including images, videos, and audio.
  • Patients can also be reached while they are in the pharmacy, encouraging them to fill and refill their prescriptions and stay educated about their prescribed therapies. An Rx triggers a personalized message for the patient, delivered by the pharmacist.


High OOP cost may lead patients to not fill initial prescriptions, not refill, or ration in order to extend their supply. Of course, the first response here is to provide solid copay assistance. But new prescriber- and pharmacist-targeted electronic prompts can augment and extend the value of copay support by:

  • Delivering real-time messages in the eRx module of the electronic healthcare record (EHR) to support prescribing behavior with clinically and contextually relevant information, including patient copay savings messages that can be passed on to patients.
  • Leveraging in-EHR capabilities that allow a brand’s copay offer (including the patient’s net OOP cost, where available) to be shown to doctors as part of real-time benefit check results, immediately before they send the prescription electronically to the pharmacy. Our internal research shows that over two-thirds of providers want to understand these savings options within the EHR workflow, and 82% will act on that information immediately for a patient.
  • Prompting pharmacists automatically and in workflow when a prescription is eligible for copay assistance. If the pharmacist foresees a significant risk of cost-based abandonment, they simply apply the copay support and then explain the manufacturer-provided savings to the patient.


Nonadherence can also occur when a patient does not understand the need for the medicine or the time it takes to see results. Similar to what we saw with “fear of side effects,” patient misunderstandings can often be alleviated by better communication and education. And here, personalized patient-focused messaging offers solid solutions:

  • Brands can help preempt patient drop-off by consolidating the patient experience into a centralized, easy-to-use mobile concierge. A patient concierge platform embeds feature-rich content into an app or mobile web experience that provides knowledge-supporting videos, customer service info, disease state information, and other content created by the manufacturer.
  • Service providers can now deliver personalized patient communications in the pharmacy to encourage healthy behaviors and improve medication adherence. An Rx triggers a personalized message for the patient, based on the Rx or drug history. The patient receives their prescription and personalized information directly from the pharmacist.
  • New technology also enables prescription-related messaging directly from the pharmacy to patients via text. This can create a stronger relationship between pharmacists and patients that results in reduced misunderstanding.

Today’s brand leaders have a wealth of resources to help support patients in their efforts to get on and stay on their medicines. Service providers offer networks and platforms that deliver key messages to prescribers, pharmacists, and patients. These novel solutions reach prescribers and pharmacists within their workflow, and can reach patients with adherence-boosting messages and financial support offers at the prescriber’s office, at the pharmacy, and directly on their mobile devices.


1. Osterberg L, Blaschke T. “Adherence to Medication.” N Engl J Med. 2005;353:487-97.

2. Lehmann A, Aslani P, Ahmed R, Celio J, Gauchet A, Bedouch P, Bugnon O, Allenet B, Schneider MP. “Assessing Medication Adherence: Options to Consider.” Int J Clin Pharm. 2014 Feb;36(1):55-69. doi: 10.1007/s11096-013-9865-x. Epub 2013 Oct 29. PMID: 24166659.

3. Briesacher, B.A., Gurwitz, J.H. & Soumerai, S.B. “Patients At-Risk for Cost-Related Medication Nonadherence: A Review of the Literature.” J GEN INTERN MED. 22, 864–871 (2007). https://doi.org/10.1007/s11606-007-0180-x.

4. Stewart SF, Moon Z, Horne R. “Medication Nonadherence: Health Impact, Prevalence, Correlates and Interventions.” Psychol Health. 2023 Jun;38(6):726-765. doi: 10.1080/08870446.2022.2144923. Epub 2022 Nov 29. PMID: 36448201. https://www.tandfonline.com/doi/full/10.1080/08870446.2022.2144923.

5. “8 Reasons Patients Don’t Take Their Medications.” AMA. Feb 22, 2023. https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications.

  • Joey Cohen

    Joey Cohen is VP, Client Solutions at ConnectiveRx. Joey is the company’s subject matter expert on EHR, eRx, and pharmacy messaging, and serves as its agency partnership liaison. He is a leader in digital marketing and strategy, with proven skills in EHR strategy, account-based marketing, CMS transformations, CRM database development, and global/local digital advertising. His broad experience in pharmaceutical manufacturing and service companies, including roles at Eisai US, Leo Pharma, and Ogilvy CommonHealth, propel his work to craft innovative in-workflow and point-of-care messaging solutions for clients large and small.


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