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FEATURE: Joanne Shaw Is it acceptable for people to be paid to adhere to medication? No BMJ 2007; 335: 233 [Full text]

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Paying addicts

Richard J Stevenson   (7 August 2007)

Is it acceptable for people to be paid to adhere to medication?

Trevor Turner   (14 August 2007)

Financial incentives for adherence

Ana B Emiliano, Suite 333, Baltimore, MD 21287 USA   (16 July 2009)

Paying addicts 7 August 2007
Richard J Stevenson, Forensic Physician Strathclyde Police, G40 3RX Send response to journal: Re: Paying addicts	As a forensic physician working in the East end of Glasgow, a very high percentage of detainees are on opiate substitution programs. From my own personal observations, nearly all are using 'top up' heroin. Additionally, there is a very high consumption of alcohol whilst on methadone. It is obvious that a £2 'shopping voucher' could easily be diverted into paying for 2 litres of cider to fund a dual addiction. I also find it ridiculous in a cash-strapped NHS service, where we are unable to fund life saving/extending medications and yet we are able to pay addicts to 'comply' with a treatment that offers no treatment benefit other than to 'reduce harm'. Competing interests: None declared
Is it acceptable for people to be paid to adhere to medication? 14 August 2007
Trevor Turner, Consultant Psychiatrist City & Hackney Centre for Mental Health, Homerton University Hospital London E9 6SR Send response to journal: Re: Is it acceptable for people to be paid to adhere to medication?	The debate between Tom Burns and Joanne Shaw seems classically representative of the wider NHS debate between a clinically informed evidence based approach and a neo-puritanical institutional correctness. Burns outlines a number of peer-reviewed references, looking at the effectiveness of rewarding patients and the notion of “the language of contract”. By contrast Shaw uses unsupported generalisations, impaired logic and a rather negative view of human motivation. Thus, Shaw states that payment for adherence “creates perverse incentives and undermines the therapeutic alliance between patients and doctors”, but where is the evidence? She suggests that “by introducing payment, voluntary adherence will disappear”, again unreferenced, and insists that “a large proportion of non-adherence is intentional”. But using “a spoonful of sugar to make the medicine go down” is part of the history of medicine, and we even agree that patients with chronic illnesses should have their medications free (i.e. they get a payment – the cost of their medication – unlike you or I who only have occasional illnesses). People may be conscious when they make choices not to take medication, but lack of insight, fear of side-effects, and the magical thinking that it will all “just go away”(if you are not someone who is a patient being medicated) are common to difficult-to-treat illnesses. Shaw also uses the reductio ad absurdum argument that we can’t imagine, can we, paying people to have lobotomies? Yet that is something you can’t even have when detained under the Mental Health Act without special dispensation. The notion that paying people “sends a signal that they need to be compensated for doing something” is equally misconceived, suggesting that I need to be paid to be a psychiatrist because I am somehow a weak person for doing that. Payment means value attached to something, and it seems just as logical to suggest that paying people makes them feel valued, and that their worth is acknowledged to society when they have to deal with very debilitating conditions, for example, tuberculosis or schizophrenia. I regularly buy sweets, nuts, drinks (usually non-alcoholic) for chronic patients who live miserable lives, or even buy them cigarettes to “sweeten” the embarrassments of having regular injections. In the USA it is possible for physicians to document whether or not patients are able to take responsibility for their own money, enabling the care worker to hand out dollars for medication, on a regular basis. Good health and socio- financial stability are behaviourally linked, which is at the heart of all health promotion material. Competing interests: None declared
Financial incentives for adherence 16 July 2009
Ana B Emiliano, Endocrinology Fellow Johns Hopkins School of Medicine 1830 E. Monument Street, Suite 333, Baltimore, MD 21287 USA Send response to journal: Re: Financial incentives for adherence	In her 2007 BMJ article on financial incentives for adherence, Shaw eloquently argues that paying patients to take their medications is not an acceptable strategy. Among the disadvantages of such an approach, Shaw lists the weakening of the doctor-patient relationship, undermining of voluntary adherence and creation of conditions leading to fraud1. In a response to the article, Collinson points out that in the case of vulnerable patients (in her experience, tuberculosis patients suffering from substance abuse, homelessness, etc), incentives, including money may be critical to ensure the safety of the individual and the community2. I work in a clinic in Baltimore, USA, where I see hundreds of patients with diabetes. Non-adherence, regretfully is very prevalent. Nonetheless, I would not normally consider offering financial incentives to promote adherence. The exception, however, is a 19-year old African- American male with type 1 diabetes since age 12. He is an orphaned, resident of the inner city, unemployed and without professional skills, who has not completed high school education. Although he still does not have diabetic complications, he will certainly develop them, given his degree of non-adherence. More alarming are the immediate consequences of his erratic insulin use: within the past year, he has had 5 admissions for diabetic ketoacidosis. Different approaches have been tried to help him, including bimonthly visits with his pediatrician and me, frequent phone calls, psychotherapy referrals, empathy and confrontation. So far the results have been disappointing, as he frequently misses clinic visits and runs out of insulin. Offering this patient financial incentive in exchange for his adherence may represent our best option at this point. The ‘reward’ would be contingent upon acceptable quarterly glycated hemoglobin levels, drawn in our clinic. This unorthodox approach is justified based on the premise that it could be a formative experience to this patient. He grew up without parental support, which is key in promoting adherence in adolescents with type 1 diabetes3. By paying him to take his insulin, we would be attempting to train him to become voluntarily adherent. Providing him a strong positive reinforcement in the form of monetary gain may empower him to move away from an immature and irresponsible attitude towards his health. Moreover, this strategy holds the potential for improving our therapeutic alliance, if the patient perceives the intervention as an investment in his well-being. Support from a physician is a powerful predictor of adherence in type 1 diabetes4. The definition of support can take many facets and providing financial incentives to enhance adherence may be one of them. Although paying patients to take their medications is not devoid of risks, the same applies to most of our interventions, from prescribing drugs to recommending surgery. In my opinion, the truly unacceptable approach is insisting on strategies that have failed, while we watch him succumb to his disease. 1- Shaw J. Is it acceptable for people to be paid to adhere to medication? No. BMJ 2007; 335:233. (4 August.) 2- Collinson S. Incentives help vulnerable patients to stay well. BMJ 2007; 335:317. (18 August.) 3- Ellis DA, Podolski C, Frey M, Naar-King S, Wang B, Moltz K. The role of parental monitoring in adolescent health outcomes: impact on regimen adherence in youth with type 1 diabetes. J Pediatric Psychology 2007; 32(8):907-917. 4- Kyngas HA. Predictors of good adherence of adolescents with diabetes (insulin-dependent diabetes mellitus). Chronic Illn 2007; 3(1):20 -28. Competing interests: None declared Editorial note The patient whose case history is described has given his signed informed consent to publication.