Viewpoint.pdfWhen patients with high blood pressure say, “I’m not a pill person,” are they really saying, “I’m more of a disease person”?

Of course not. It’s not so much that they’re okay with the chronic condition or potentially suffering its downstream complications. It’s more that they fear the risks of the medication more than the risks of the disease.

As a neurosurgeon who has managed end-of-the-line complications of poorly controlled high blood pressure—in the form of bleeding deep within the brain and other highly undesirable results—the risks of the disease loom large in my mind. But I acknowledge that a rare window into risk shapes my views.

Given the window that most people have access to, I think the risk of the drug often looms large. Think of the alarming package insert. The important safety information. The fast talk at the end of drug ads on TV. The neighbor’s tale of nasty side effects.

But where are the countervailing warnings of doing nothing—the risks of the disease itself? Without a clear side-by-side comparison, how can patients accurately weigh side effects versus disease complications? Clearly, many people end up choosing inaction. 

Approximately 28% of patients who are newly prescribed a medication for high blood pressure do not fill the prescription at all, not even once. Of those who do fill at least once, only about half continue to refill for an entire year—many having quit against medical advice, often within the first three months.

Interestingly, this medication nonadherence is not due primarily to drug cost, as is often assumed. Offering medication for free improves these numbers by only a little. Countries with significantly lower drug costs than the US demonstrate similar nonadherence rates.

What is it about medication risk that tends to scare people more than the disease? Drug risk often presents itself quickly, while disease risk is metered out more slowly (which is less scary). In the case of poorly controlled or uncontrolled high blood pressure, the insides of blood vessels throughout the body are damaged very slowly, as a form of slow-motion trauma. The ensuing stroke or heart attack may not occur until years after the diagnosis of hypertension.

Looked at in a different way, the fact that chronic medications tend to offer only long-term benefits poses a psychological challenge: We prefer our benefits now rather than later. Then there’s the distaste for anything “unnatural,” especially as offered by Big Pharma. But one must ask, What is worse: an unnatural pill or a natural blood clot within the brain? Sometimes nature is not kind and its manifestations are to be avoided.

Beyond the barrier of risk perception, there are also the annoyances of starting a medication that turn people off. Until the promise of personalized medicine comes true, we’re often stuck experimenting with different drugs and doses to find the right mix for the right patient. This can require multiple visits to the physician and pharmacy … and the feeling of being a guinea pig.

What we’re left with, then, are drugs that can work well and many patients who prefer to live with the risks of the disease. For certain, the development of more effective and safer drugs would be ideal—as would the development of better drug alternatives, so that we wouldn’t have to be pill people at all. For now, though, if we want to improve outcomes and lower healthcare costs, we’ll need to come up with more creative ways to clarify risk all around.