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Melanie Cole (Host): If you have a senior loved one or you are on many medications, you know that that lengthy list of medications that you have to take on a daily basis can be very difficult to remember and to manage. Today, we’re talking about medication management and adherence. What a great topic. My guest is Dr. David Twitchell. He’s the Vice President and Chief Pharmacy Officer at Boston Medical Center. David, I’m so glad to have you with us. As I said, this is a great topic. I have a father who is 95, he’s on a bunch of different medications and it’s difficult to keep track. Tell us why medication management is so important and how many hospitalizations lead every year to people being hospitalized for overtaking medications, forgetting medications, to general adherence.

David Twitchell PharmD, MBA (Guest): Yeah great question and first of all, thanks for having me. Medication is so critically important because almost every chronic disease that we treat and even acute conditions, the one common theme that comes through on all of them is they often require medication to treat them. We see at Boston Medical Center, we operate ACO, we take care of lots of patients both in the hospital and in our community and we see what you see nationally. Lots of chronic disease treatment failures for people who have a disease that can be treated and should be treated on medications, almost half the time, the reason they fail, is because they don’t take their medications, or they don’t take them properly.

I think this is my recollection but there is certainly published data on this. There are hundreds of thousands of deaths that can be attributed to some form of medication adherence deficit. And so, it couldn’t be more important than when you know over half the time a disease treatment fails or hundreds of thousands of deaths occur as a result of nonadherence or medication adherence errors. It certainly kind of rises to the top of importance for me and for our health system. We think a lot about it.

Host: And as you say, mismanagement of medications can lead to hospitalizations and so many people have this polypharmacy. They are on many medications. So, what are some of the most common mistakes that you see when people are on multiple medications?

Dr. Twitchell: Yeah, I think – what we know is as you go on more medications, there’s a threshold at five and certainly again at ten; you start to see patients making more and more mistakes. The first and the most common thing that people think of is interactions. And that’s definitely true. The more medications you are on, the greater your polypharmacy burden if you’d like is; the greater the chance that you end up with an interaction that can either decrease the efficacy of one of the drugs, how well one of those drugs works or completely negate it or the opposite can happen. It can increase the amount of another drug that ends up in your system to a level that may be dangerous or make it have side effects that it wouldn’t otherwise have at normal levels.

Another thing that happens is maybe a little less obvious but pretty intuitive which is if you are on ten medications, good luck keeping track of all of those. And particularly you spoke about your father, think about also here in Boston, we have folks who may be functionally illiterate, who may have low health literacy. I’ll use myself as an example, I’m trained in pharmacy, I was a clinical pharmacist for many years, I’m on two different medications and sometimes I mix those up. So, with the highest level of training on medications, specifically trained as a pharmacist; I know I have trouble sometimes remembering to take my medications. Add on the burden of age and dementia or any other challenge and then increase the number of medications you are on. Well the likelihood that you are going to get all of that right without some form of support is probably low.

So, I think of those two things as the main things that go wrong either the patient has too many things to keep track of and can’t be successful on all of those or there’s interactions or enough medications that they end up having untoward effects and they don’t feel well, and they are not getting the outcomes they intended to have with all those medications.

Host: So, I want to spend the most of our time David, talking about things we can do to help manage those medications but are there some signs, very briefly that you’d like us to know like if we are taking care of an aging parent, pills on the floor or you are not quite sure if the person that you love took this particular pill or maybe took too many. Are there any signs you want us to look for mismanagement?

Dr. Twitchell: I think you mentioned a couple of them. Certainly if you see pills around, I think the best advice I can give is to get educated about what your loved ones are on and how they are supposed to be taking it and what it’s for. And you don’t have to be a technical expert, but you can know that there’s for example a heart pill and a water pill and those are really okay terms to describe the pills. Because people know and certainly your physician, your nurse, your pharmacist are going to know what you mean when you say water pill, it’s the diuretic and we’ll think in the technical terms.

But if you can know what it’s for and know how they are supposed to be taking it; then one you can look for those signs. You can also take one step deeper and actually take a look. So, one of the tricks that we have are technical nonclinical staff do when they go into the homes or do phone interviews, just as an example, if somebody has 30 tablets every month, they are supposed to take one every day; you can simply count what’s left since the last time you came. It’s kind of an easy trick so if you know it’s fifteen days since you last saw your loved one, and there are still 30 tablets; well you can do the math and you know that they are not taking it. Or if they are all gone, a different problem and they are taking them all.

The other is to look for things or they suddenly become confused as they started new medications. Behavior has changed is really a softer signal. They may be taking the drug exactly right but because you’ve added a drug to a complex regimen, the ninth drug in a compliment of what they were on eight and they added the ninth and all of the sudden their behavior changed. It may be the medications. So, paying attention to their behavior as things change around their medication therapy is another important thing to see if they are doing well or not doing well or perhaps, they’ve changed how they are taking their medication.

Host: Okay. So, what can we do. Now first of all, pill boxes have been around forever, and I remember that they had the little days of the week on them and you put your little week pills all in there. Does that still work? Should we be keeping a list of our medications in case someone has to go to the hospital or do you like it on a little zip drive? How can we keep track David? What should we be doing?

Dr. Twitchell: Well I think you named two. One, I really like the second thing that you said. having a list of your medications even on a piece of paper. I know my grandfather had a little notebook in his pocket at all times. I always have my wallet so that’s where I keep my information. If you can write it down and the basics of what it’s for, it’s incredibly powerful. Zip drives and technology are all very interesting but difficult to use in the moment. When people either have a medication bracelet if you have enough and you have enough diseases that require people to be aware, that’s great to have but it could be as simple as a piece of paper. If you can have that, you can do a good job remembering it.

Pill boxes have been around a long time because they work. If they are used, if they are managed, I think it’s a great tool to remind you or remind me for example, it’s been a great tool for me to remember have I taken my vitamin today or did I not take it today. All my mornings kind of blend together so having that type of calendar organization, if it’s not a pill box you can certainly use a calendar instead. People all work in different ways.

There’s other thing to remember. It’s stuff like when travelling. It’s keeping your meds in your carry on. I can’t tell you how many times our pharmacy does a lot of prescriptions over a million prescriptions a year and a lot of what we fill is emergencies. People go to Florida, they pack their bag, their bag got lost. This is an easy way to lose track of your medications or to get off of the routine.

Other tricks, it’s about finding support and so I mentioned that earlier. You’ve kind of mentioned it several times. Trying it alone is almost the surest way to failure. All of us have our faults and can’t remember everything every time, myself included. My support is my wife. She does a great job reminding me when I’m supposed to take my medications, asking me if I have taken the medications. She said to me once that love is spelled N-A-G because she keeps track of me and takes care of me. So, if you can find a support network, there’s no better way to ensure that you are well taken care of. And sometimes that’s in the form of family. For us, we’ve tried to put resources in place I think the pharmacist has a very important role to play as doe pharmacy in general.

Here in Boston, we’ve done a lot of work to get folks like pharmacy technicians and pharmacists more involved over time. We call it longitudinal. It just means month to month. We actually don’t instruct the patient in January to take the medications a particular way and then see them the next January and realize it didn’t go well. We are trying to be a better part of that support network by talking to the patient every month, seeing them every couple of months to make sure that they are still doing well. Doing the checks that I mentioned to you as the professionals who are best trained to do that, I think we’ve had a great deal of success getting patients on their medications. If you are listening to this and you have a loved one, you can be that support network. It is just as simple as kind of knowing what they are supposed to be taking and tracking that month to month. That’s what they need. They can’t do it themselves. You can’t do it yourself. Look for help or be the help and I think that’s the best advice overall in general I can give.

Host: And that is great advice. What a perfect way for us to wrap up. Do you have any final thoughts that you would like to tell the listeners David, about the importance of managing those medications, adherence and just medication advice, really?

Dr. Twitchell: My parting thought would be medications today are absolutely amazing. There are diseases that ten years ago we couldn’t imagine being where we are now. We can cure hepatitis C, we can manage HIV, almost into nonexistence. It is miraculous is kind of the only word I can think of and we see a lot of that here. We have a lot of specialties. And I’m constantly amazed by how wonderful it is. The key though is you got to take it. And the difference between taking it and not taking it in HIV for example is a patient who lives an entirely normal life, almost disease free and dies of old age which is the best possible outcome we can think of for those diseases and there couldn’t be a more exciting time to have the medicines available to us because they are doing things we never thought were possible in all sorts of disease states.

But the key is you have to take them, you have to take them right and you have to not have things that are interfering with it. Coupled with that, by the way, is don’t be ashamed of the fact that you are not perfect. I’ve mentioned several times, I’m not perfect. But I try to do the best I can and just like with the dentist, you don’t have to lie to your pharmacist or your doctor, tell them how you struggle because it’s the best way to get help. And reach out and get help either from your professionals or your family or your network because again, you don’t have to be perfect, but you do need to do pretty well. And you don’t have to do it alone. I would stop at that.

Host: Wow, what great information and so important for so many of us to hear as many of us are on multiple medications or someone we know is on multiple medications. So, this is really important for everybody to learn from you together. Thank you again for joining us.

That wraps up this episode of Boston MedTalks with Boston Medical Center. You can head on over to our website at www.bmc.org/pharmacy for more information and to get connected with one of our providers. If you found this podcast as informative as I did, please share on your social media, share with friends and family that you know that are on multiple medications and maybe need just a little help managing those medications. And be sure to check out all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.