Evidence and tips on the use of medication compliance aidsBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2801 (Published 19 July 2018) Cite this as: BMJ 2018;362:k2801
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The Practice Pointer paper “Evidence and tips on the use of medication compliance aids” is a timely and helpful guide to using medication compliance aids (MCAs) and the authors have grasped many of the important concepts of MCAs but we suggest some important recent evidence has been overlooked.
Although there is little evidence per se that MCAs are effective in improving health outcomes , organisation devices may help unintentional medication non-adherence. The authors of the position paper seem to suggest MCAs may be useful for any type of unintentional non-adherence and did not mention the potential harm of significant and sudden adherence for people who previously have been non-adherent. A 2016 Health Technology Assessment reviewed the effectiveness of MCAs which informed a feasibility RCT . The RCT concluded that MCA provision to unintentionally non-adherent older people may cause medication-related adverse events.
In addition, electronic MCAs were reviewed in a 2016 paper  and there was some evidence that these more sophisticated devices could be helpful in overcoming some of the issues identified with MCAs. The elderly with cognitive problems and patients with conditions where timing and adherence to medication regimes are critical were the groups most likely to benefit from these reminder devices.
The position paper indicates that to comply with the Equality Act there is 'little standardised assessment available. Therefore often with minimal background information about the patient, the pharmacist must provide such an adjustment......' The Identification of Medication Adherence Barriers Questionnaire IMAB-Q  is a standardised assessment that has been developed and validated to support patients and practitioners to identify barriers to adherence including practical difficulties (such as getting to the pharmacy or being unable to swallow medication) and/or perceptual barriers (such as lack of motivation or negative emotions). This questionnaire is freely available for pharmacists to use as required.
In summary, medication adherence is complex. Whilst there may be a benefit for some patients in using medicine compliance aids, they may not always be of benefit and indeed their use may sometimes have serious consequences. It is recommended that prior to recommending a medication compliance aid, the patient’s medication taking behaviour must be fully understood, ideally using standardised validated tools.
 Watson, S.J., et al., Systematic review of the health and societal effects of medication organisation devices. BMC Health Services Research, 2016. 16(1): p. 202.
 Bhattacharya D, Aldus CF, Barton G, Bond CM, Boonyaprapa S, Charles IS, et al. The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial. Health Technol Assess 2016;20(50)
 Paterson,M., Kinnear,M., Bond,C, McKinstry,B., A systematic review of electronic multi-compartment medication devices with reminder systems for improving adherence to self-administered medications, IJPP 2016
Competing interests: No competing interests
The population with intellectual disabilities is subject to health and healthcare inequalities and inequities. It is important that the decision to use Medication compliance aids (MCAs) does not widen these health and healthcare inequality and inequity gaps.
MCA should only be issued on a case-by-case basis to address specific practical problems of medicines adherence in an individual with intellectual disability (ID). There should be discussions with the person with ID and / or their carer about any practical problems resulting in non compliance with prescribed medications. All options available to improve compliance should be explored.
• The inappropriate use of MCA may disempower a person with ID and may make the person and their carers less familiar with prescribed medicines. Person and carer, health literacy including awareness of medicines should be promoted.
• Transferring medicines to a MCA carries the risk of human error. Patients are the last defence against the administration of an incorrect medication. The use of MCA by a person with ID and /or their carer with limited health literacy lessens the defence.
• The dexterity of many people with ID is compromised. Pharmacists should check compliance issues and provide a MCA only if compliance cannot be addressed by other methods and the patient with ID/ carer has the dexterity and health literacy to use the MCA.
• Patients with ID may only have part of their medication regimen supplied in a MCA with other medications provided in their original containers, leading to confusion and the risk of non adherence. Managing two different systems increases complexity and safety risks.
• Patients with ID who use MCAs some of which are stored in the fridge and some out of the fridge may be at risk of non adherence if either is overlooked, forgotten, etc
• The level of support available to the patient with ID should be understood. Does the person with ID self administer? Is the patient with ID supported by family and / or trained/registered staff?
• Patients with ID using a MCAs should be assessed regularly for appropriate and safe use.
• People with ID are regular attenders in accident and emergency (A&E) departments. The use of a MCA by a person with ID and limited communication skills and poor health literacy may lead to diagnosis difficulties when A&E staff have difficulty identifying prescribed medications.
Competing interests: No competing interests