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Pharmaceutical Manufacturing and Packing Sourcer

Adherent Packaging

Finding ways to reduce healthcare costs has never been more important; Ted Lithgow of MWV Healthcare puts the case for adherence-enhancing pharmaceutical packaging

Although Europe, the US and Japan appear to be showing signs of economic recovery, economies worldwide are still reeling from the effects of the financial downturn. Governments are seeking to rein in costs, and funding allocations for healthcare will not escape the budgetary knife. In 2009, unprecedented health budget cuts across Europe averaged six per cent, despite numerous initiatives aimed at safeguarding health (1). As a result of this and other contributing factors, the pharmaceutical industry is under increasing scrutiny to demonstrate the value and cost-effectiveness of its products to healthcare payers. Improving medication adherence is a straightforward and proven way to reduce healthcare costs and increase patient benefit.

Poor medication adherence – not following medication regimens as directed – is a pervasive problem that is recognised increasingly as a considerable source of waste in healthcare systems. Additionally, poor medication adherence results in a significant negative impact on patient outcomes.

A report from the World Health Organization (WHO) estimates that in developed countries, only 50 per cent of patients who suffer from chronic diseases adhere to treatment recommendations. The report goes on to explain that “poor adherence to long-term therapies severely compromises the effectiveness of treatment, making this a critical issue in population health both from the perspective of quality of life and of health economics. Interventions aimed at improving adherence would provide a significant positive return on investment through primary prevention (of risk factors) and secondary prevention of adverse health outcomes” (2).

Non-adherence is also a drain on healthcare systems. A costing statement published by the National Institute for Health and Clinical Evidence (NICE) in the UK states, “medicines supplied on prescription cost the NHS £8.1 billion in 2007 to 2008. If as many as 50 per cent of patients don’t take their medicines as recommended, this could mean that £4 billion of medicines are not used correctly”. However, non-adherence has an impact on more than just the cost of wasted medicine. The NICE costing statement reports that the costs of hospital admissions due to patient non-adherence in 2006 to 2007 are estimated to be between £36 and £196 million (3).

Adherence-enhancing packaging is a simple, proven way to realise cost savings, create efficiencies for doctors and pharmacists, and provide tangible health benefits to patients. As countries worldwide grapple with the task of streamlining healthcare costs, it is critical that we invest in developing and providing incentives for using adherence-enhancing packaging and other adherence solutions to assist with the inevitable budget cuts.


Non-adherence is defined by several behavioural patterns, including failure to collect prescriptions, failure to follow day-today instructions (for example taking too many or too few doses, or taking doses at the wrong time), and failure to collect subsequent prescriptions as directed.

Data from a survey commissioned by the National Community Pharmacists Association (NCPA) in the US found (4):

  • Half of those polled (49 per cent) had forgotten to take a prescribed medicine
  • Nearly one third (31 per cent) had not filled a prescription they were given
  • Nearly three out of 10 (29 per cent) had stopped taking a medicine before the supply ran out
  • One quarter (24 per cent) took less than the recommended dosage

There are several explanations for poor patient adherence including (5):

  • Medication factors such as regimen complexity and concern over side-effects
  • Patient factors such as denial of illness, cost of medication, the assumption that medication can be discontinued if one feels better, and forgetfulness. For the elderly, complying with medication instructions can be particularly daunting, as people over 65 years of age fill almost 30 prescriptions per year
  • Prescriber and pharmacy factors including poor patient communication and inadequate compliance counselling, often limited by time constraints
  • Geographic variations in patient adherence While there is little or no data to suggest differences in adherence due to socio-economic status, there is evidence that patient adherence to medication varies substantially between countries (6-8).

The European Community Respiratory Health Survey (ECRHS) collected data from 1,771 patients with asthma from 14 countries. The compliance of those patients who had received a medical prescription (95 per cent) was found to be low in all countries (the median was 67 per cent) but with broad variations, ranging from 40 per cent in the US to 78 per cent in Iceland. The study documented that compliance to the treatment of asthma is poor worldwide, with significant variations between countries.

To test the hypothesis that socio-economic influences could be at play, researchers from the Institute of Public Health in Denmark conducted a survey in 2009 of 45,678 participants. The survey assessed socio-demographic and socio-economic variables and concluded that this is, in fact, not the case. They suggested instead that other factors such as differences in the availability of medications between countries, differences in the prevalence of specific diseases or conditions and health insurance systems may be the cause, although cited the need for further research (8).


Poor compliance may have a far greater impact on the health of the population than any improvement in specific medical treatments (9).

The consequences of poor medication adherence are well documented; study after study shows the enormous negative effect it can have on patient outcomes and economic costs. The American Heart Association reports the following (10):

  • Ten per cent of all hospital admissions and 23 per cent of all nursing home admissions are the result of patients failing to take prescription medications correctly
  • The average length of hospital stays due to medication non-adherence is 4.2 days

A study in the British Journal of Psychiatry found that patients who failed to adhere to their medication regimen were more than 1.5 times as likely as patients who did adhere to it to report use of in-patient services. Non-adherence was identified as one of the most significant factors in increasing external service costs. Non-adherence predicted an excess annual cost per patient of approximately £2,500 for in-patient services and more than £5,000 for total service use (11). Proper patient compliance promises the best possible outcome of the treatment provided. By contrast, poor compliance prejudices a favourable outcome and can be harmful to the patient. In addition, there can be significant cost implications if medication is wasted or the patient requires additional treatment due to poor compliance.


One answer to the problem of poor medication adherence is pharmaceutical packaging that is designed specifically to address the barriers to patient adherence. Well-researched and designed packaging can make a major contribution to patient adherence with respect to:

  • Ease of identification
  • Clarity of instructions
  • Visible evidence of medication taken (12)

Known as adherent packaging or adherence-enhancing packaging, this type of packaging employs methods such as blister packs that are labelled with days of the week to help keep patients on schedule. Packaging may also include written directions that stress the importance of complying with the physician-prescribed regimen.

The FAME study, published in the Journal of the American Medical Association, demonstrates the value of adherent packaging. The study showed that blister packs of blood pressure medication combined with pharmacist counselling improved adherence among elderly patients by nearly 40 per cent compared with regular vials and no counselling. As a result, these patients experienced statistically significant reductions in their systolic blood pressure (13). Researchers concluded that “provision of blister-packed medications was a key component of the medication adherence programme”. Despite its benefits, adherence-enhancing packaging is underused. One explanation may be the slightly higher cost involved compared with traditional packaging.

Adherence-enhancing packaging may also have a benefit beyond improving adherence. An extensive 2006 report by the US Institute of Medicine found that blister packaging can reduce the incidence of medication errors and their consequences (14). The report noted that 1.5 million Americans become unwell, injured or killed by medication errors, and that “many medications would be better dispensed in blister packs that make it easier to identify them and for consumers to remember whether they have taken that day’s dosage”.


The European Healthcare Compliance Packaging Council (HCPC) is currently conducting a survey among patients to assess what they are looking for in terms of packaging solutions. Although the full results have not yet been published, preliminary findings indicated that patients are looking for calendar packs, reminder features – both conventional and electronic forms, and combination packs. The HCPC has also identified some issues which may need further consideration, for example colour coding, monitoring and accessibility.


Looking to the future, more advanced forms of adherenceenhancing packaging hold even greater promise of optimising patient outcomes. For example, ‘smart’ technology memory chips, which can record or transmit the exact time and quantity of medication taken, use alarms to prompt patients to take their medicine and answer survey questions about patients’ conditions. Special readers or automated communication solutions can then download their information to healthcare professionals, enabling them to assess patient behaviour and intervene as appropriate. Eventually, this technology will allow packaging to self-transmit data automatically to healthcare professionals.

Future innovations will use automated technology to package multidrug regimens into a single pouch with the exact number of pills to be taken in the morning, midday and night. This technology may dramatically simplify administration of complex drug regimens, with particular benefits for the elderly or chronically ill.


The benefits of improving adherence are clear and the technology exists to improve patient health without increasing the cost of healthcare. The widespread use of adherence measures, including adherence-enhancing packaging, have the ability to significantly improve patient outcomes while reducing unnecessary costs in healthcare systems.


  1. European Federation of Nurses Associations (EFN) Report on the Impact of the Financial Crisis, version1/en/ documents/EFNMembersReportonFinancialCrisis- April2009.pdf, accessed 18 March 2010
  2. WHO Report: Adherence to Long-Term Therapies: Evidence for Action, adherence_report/en/index.html, accessed 19 March 2010
  3. NICE Costing statement, Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, pdf/CG76CostStatement.pdf, accessed 18 March 2010
  4. National Community Pharmacist Association, Non-adherence is still a major problem, Drug Topics, 22nd January 2007, leDetail.jsp?id=398007, accessed 29th April 2010 5
  5. Enhancing Prescription Medicine Adherence: A National Action Plan, Report by the National Council on patient information and education, August 2007
  6. Cerveri I, Locatelli F, Zoia MC et al, International variations in asthma treatment compliance: the results of the European Community Respiratory Health Survey (ECRHS), Eur Respir J 14: pp288-294, 1999
  7. Larsen J, Vaccheri A, Andersen M et al, EU variations and social influences: Lack of adherence to lipid-lowering drug treatment, A comparison of utilisation patterns in defined populations in Funen, Denmark and Bologna, Italy, J Clinical Pharmacol 49(5): pp463-471, 2000
  8. Larsen J, Stovring H, Kragstrup J and Hansen DG, Can differences in medical drug compliance between European countries be explained by social factors? Analyses based on data from the European Social Survey, round 2, Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark, BMC Public Health 9: p145, 2009
  9. Haynes RB, Yao X, Degani A et al, Interventions to enhance medication adherence, Cochrane Database Syst Rev, 19 Oct, (4):CD000011, 2005
  10. Statistics You Need to Know, American Health Association, accessed 19 March 2010
  11. Knapp M et al, Non-adherence to antipsychotic medication regimens: associations with resource use and costs, Br J Psychiatry 184: pp509-516, 2004
  12. What do we mean by compliance? Healthcare Compliance Packaging Council Europe, cms/front_content.php?idcat=3, accessed 17 March 2010
  13. Lee JK, Grace KA and Taylor AJ, Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure and Low-Density Lipoprotein Cholesterol: A Randomized Controlled Trial, JAMA 296: pp2,563-2,571, 2006 14. Kaufman M, ‘Medication Errors Harming Millions’ Report Says, Washington Post, 21 July 2006

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Ted Lithgow is the President of MWV Healthcare. He is responsible for setting direction, and facilitating commercial strategy and implementation for all MWV products targeted for pharmaceutical customers and healthcare professionals. He has held senior Rx and OTC Commercial Leadership positions in marketing and R&D at Schering-Plough, Pharmacia (Pfizer), Wyeth, and Warner Lambert. He was a member of the Global Business Management Team, the corporation’s Research Leadership Committee, the Exploratory Development Committee, and Pharmaceutical Leadership Board governing bodies at Pharmacia and Schering Plough. Ted is a psychopharmacologist trained at The City University of New York and Albert Einstein College of Medicine in Bronx, New York.
Ted Lithgow
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