Motivational Interviewing

Editorial Note: Motivational interviewing began as a technique to help opiate or nicotine addicts or alcoholics. The idea was to move them through contemplation of the possibility of change, to having an action plan and then acting. It recognized that there was no point just arguing that addiction was wrong – you had to understand a person as well as they understood themselves to be able to get them to change. But this technique to get people off drugs has been picked up by pharma to get you on drugs… as the post below and one to come from Johanna Ryan bring out.

My time to quit

My friend Rick quit smoking in 2008, with a little help from a drug called Chantix, made by Pfizer. He first heard of it from a teaser ad they ran on TV, in which smokers declared that it was “My Time to Quit.” That made sense to Rick. He was a recovering alcoholic who had finally put together three years of sobriety. He’d reconnected with his old college sweetheart after thirty-odd years, and at the age of sixty was engaged. Now was the time, he figured. Quitting smoking was all the more important because Rick had a pacemaker in his chest and serious heart problems.

That made me nervous. Chantix, you see, is a drug with serious hazards. By 2008 it had a grim reputation for causing aggression, anger, depression, violence, even suicide. It was one of the very few drugs airline pilots were categorically forbidden to use, and was on its way to an FDA Black Box Warning for its psychiatric side effects.

Want a heart attack? – stop smoking

What were less well known were Chantix’ cardiac risks. Yet Pfizer already knew plenty, although they had succeeded in keeping that information off the official label. A string of problems from heart attacks to cardiac arrhythmias to chest pain had surfaced in clinical trials. In the EU they were classified as uncommon, but drug-related. Independent voices in medicine were warning that, at the very least, this was not a drug for people who already had heart problems.

What’s a friend to do? I kept nagging Rick to at least “ask his doctor” if a man in his condition should be using Chantix. But he liked the stuff, and felt it was helping him quit. He especially liked their cool e-mail support system. [https://www.chantix.com/getquit-plan.aspx]. As a career advertising man, I think he wished he’d thought it up. You log on to the website, he explained, and report your progress. They congratulate you as your smoke-free days pile up, and show you how much money you’ve saved on cigarettes. You get little daily e-mails with individualized tips. If you do slip up and have a smoke, they encourage you to get back on the wagon. It sort of keeps you focused on quitting.

Rick was becoming a poster boy for something called Motivational Interviewing. At the time, I’d never heard of it – but Pfizer certainly had.

Adherence – compliance

These days drug company marketers are obsessed with what they call the “adherence problem.” To put it simply, doctors can write prescriptions all day, but the company won’t get paid until patients fill them and take the drugs. And very often, we don’t. According to “Patient Adherence: The Next Frontier in Patient Care,” an industry report by CapGemini Life Sciences, only 69% of us fill the first prescription, with rates dropping to 43% at six months. Adherence rates run about 50% for depression, and only about 60% for oral cancer chemotherapy.

Industry sources like to point out that billions of dollars are spent treating illnesses that could be prevented if people would only take their pills as directed, and in some cases I’m sure this is true. What can’t be disputed, however, is that it also takes a direct bite out of Pharma’s revenues – about a 36% loss for the average drug, according to that CapGemini study. The same report also reminds companies that their drugs might be mistakenly viewed as ineffective if patients who get prescriptions but never actually swallow the pills are counted as users. To quote Dr. Andree Bates of Eularis.com, another marketing consultancy, “Adherence is critical to improving patient health and to improving the economic health of the Pharmaceutical Industry.”

[http://www.pharmaphorum.com/articles/approaches-to-improving-patient-adherence-part-1]

MI

Motivational interviewing has become a buzzword among those trying to get us to take our meds more reliably, particularly drug companies. Ironically, it’s a technique originally developed for counseling alcoholics and addicts – people who need help learning how to say No to drugs, not Yes.

Motivational interviewing seeks to go beyond simply telling people what they must do for the sake of their health – an approach that most people with addictions are very good at resisting. Instead, the idea is to begin by listening. Discover what the person’s motivations are to adopt healthier behavior, and what ideas or habits stand in the way of change. Then feed the person’s own motivations back to them, coupled with selectively chosen information that will encourage them to make the choices their counselor believes are right.

I can’t help but picture Rick listening to my worries and getting just a tad bit nervous… only to go home to a cheery email reminding him how much he wanted to quit smoking and how important it was to his heart health (true enough). Pfizer would congratulate him on the progress he’d made and even remind him what a true gift this was to his fiancée and his grown son… quitting now, to make sure he’d be there for them for years to come.

Except that wasn’t how things turned out.

A few months later the cardiac surgery Rick figured he would “probably” have to have “someday” became urgent, NOW. He had a massive stroke on the operating table, lingered for a few miserable months unable to speak, and died. Instead of making wedding plans, his fiancée found herself organizing a memorial meeting. Three years after Rick’s death, in 2011, the FDA finally put those cardiac warnings on Chantix’ label.

Mother’s little nudges

I don’t know for sure that Rick would have lived longer if not for Chantix – he had heart problems to begin with, of course. And Pfizer is still arguing that whatever the “possible” risks of Chantix are for people like him, continuing to smoke is more dangerous. But I am pretty sure there were safer ways for him to quit smoking, whether hypnosis, “tapering” with nicotine gum or patches, or behavioral approaches. To this day, there’s no real evidence that Chantix is superior to those methods, even if it’s better than a placebo. But he’d never hear any of that in those chirpy, encouraging little emails. Nope. They were there to help him “stay focused.”

That’s the problem with Motivational Interviewing, Pharma-style. Do I really want a drug company employee using the latest psychological techniques to “motivate” me to do what he thinks is right? Clearly, his “motivation” is to get more people to take more of his employer’s product. But what if that happens to conflict with my best interests – as I truly feel it did for Rick? Can I count on my customer-support person to do the right thing?

Most of the literature on Motivational Interviewing focuses on “pharma-friendly” reasons for patient non-compliance, i.e., those for which pharma has ready, positive-sounding answers. An article aimed at pharmacists explains that maybe the patient is feeling much better now, and doesn’t realize his continued well-being depends on keeping up the meds. Maybe he’s got three pills to take, at different times of the day, and he just needs help remembering. Or maybe he thinks his condition is not so bad (his blood pressure is not as high as Dad’s, or he “only” smokes a half-pack of cigarettes a day) and doesn’t realize the long-term damage that could result.

The hidden gorilla

Some of these may indeed be valid concerns (take, for instance, the need to finish a course of antibiotics even if your fever is gone, or to control very high blood pressure even if you’re not feeling any symptoms). They will feel righteous to patient and doctor alike. Of course, sometimes the patient is right: his “borderline” hypertension or “pre-diabetes” might be better handled with a few lifestyle changes. If he’s got mildly high cholesterol but no heart disease, maybe it doesn’t need treating at all.

In either case, the focus will generally stay off the real 800-pound gorillas in the room: high prices, serious side effects, and drugs that may simply not work. For instance, psychiatric advocates argue that patients’ reluctance to take meds is a classic symptom of their illness – lack of insight into their own condition. Or they draw doctors’ attention to the patient’s possible resistance (conscious or unconscious) to getting well and letting go of whatever comfort or safety they find in the “sick role.” Get clinicians to focus on these as the main reasons for resistance to meds, and they will slide right on by the patient’s legitimate concerns about side effects and lack of actual efficacy. The psychiatrist has been motivational-interviewed right along with the patient.

A drug like Chantix puts a spotlight on the dangers. After all, people with heart disease and serious mental illnesses are prime targets for stop-smoking campaigns – and for good reason. Smoking is about the worst thing you can do for your heart, and people with chronic mental illnesses like schizophrenia are far more likely than average to be heavy smokers. Yet these are also the very people most at risk for being harmed by Chantix. Pfizer has devised a program that mobilizes their “best” aspirations for healthy living to get them on what could be the worst drug in the pharmacy for them.

But Chantix is far from the only drug to be marketed with such techniques. In the case of new and highly profitable biologic drugs, the strategy may not be to get the non-compliant patient into the doctor’s office to deal with his illness. Instead, it targets the patient who’s managing his disease with an inexpensive and well-studied drug, and seeks to convince him to switch to a very expensive one with greater risks. The patient is then helped to “educate” his doctor on the need for “change.” We’ll take up this type of marketing in Part Two.