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Rethink Medication Adherence With Sustainable Multidose Packaging

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Medication nonadherence carries a $500 billion price tag in the United States.

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Trevor Noye, senior vice president of medication adherence at Jones Healthcare Group, sat down with Drug Topics® to discuss the work that Jones Healthcare Group is currently undertaking to improve the patient experience, from medication adherence packaging to the use of sustainable materials.

Trevor Noye: Good morning. My name is Trevor Noye. I'm the senior vice president of medication adherence at Jones Healthcare Group. Jones is a global provider of advanced health care packaging and medication dispensing solutions, including medication adherence packaging dispensed to patients by pharmacies. I’m really happy to be here.

Drug Topics®: Can you provide a high-level overview for the different options for medication packaging?

Absolutely. Here in North America, most oral solid dose drugs are repackaged by pharmacies into prescription vials before they're actually dispensed to patients. Some medications are dispensed in their original pharma packaging. We're seeing now many of the online pharmacies…actually repackaging into pouches.

All packaging basically serves a purpose to protect drugs—but not all packaging is equal when it comes to trying to help patients keep track of their medications, especially for those patients who are managing multiple prescriptions at once. When we think of original pharmaceutical packaging and vials, they're not really labeled or organized by days of the week and times of the day. If you think about a patient who's on a multiple medication regime—many drugs, different times of the day—it's a pretty daunting task for them to have sitting in front of them this sea of vials as well as original pharmaceutical packaging, trying to remember what they need to take when and, as importantly, in what doses. Then, think about that same patient on the go: You're out for a day trip and it's really not easy for you to take all of these drugs along with you, and remember which ones to take.

This is really where medication adherence packaging comes in. A blister pack, which is our simple term for it, very easily organizes medications by time of day and day of the week. It's visual; you know when you've taken meds, you know when you haven't taken meds. And the real winner here is, that medication adherence pack is filled by a pharmacy technician and checked by a pharmacist before it's ever given to the patient.

In addition to that, getting your medication out of a medication adherence pack is pretty easy; just simply puncture the blister and then peel back the label and take the meds.

Drug Topics®: How do these different options affect patient access and adherence?

Noye: I'll give you a few stats that cause us to really lie awake at night: One study in the US found that over 60% of patients misunderstood their physician’s directions immediately after leaving their office. A number of studies have confirmed that the relative medication adherence rates for older patients is less than 50%; it hovers around 45%. We take those 2 statistics into account—number one…is confusion on your medication regime, what you should be taken when.

And then…as patients age, 1 in 2 are nonadherent. Now, we need to start to think about, what are the impacts of that? For the patient, nonadherence can lead to a worsening of disease, decreased functions, certainly an impact on quality of life, but also higher rates of hospital readmission. Now you think about, what are the broader impacts of medication nonadherence on the overall roughly 25% of all hospital readmissions in the US year in and year out are the result of medication nonadherence? It's a staggering $500 billion a year in preventable costs to the healthcare system as a result of medication nonadherence.

This is where medication adherence packaging can really come in and play a super role here. It can simplify a patient's med regime and allow them to take the guesswork out of what they're doing. No more double dosing; you know when you've missed a dose. It's organized by time of the day and by day of the week, so on Tuesday for your morning meds, you know what you need to take.

We've also got tamper evidence, which can be a big deal. Multiple medications sitting around in the house are easy targets for younger children to play with, or for those who have some more sinister capabilities for drugs being diverted. With a medication adherence, pack tamper evidence is easy. If somebody's broken into that blister, we know; if Tuesday morning’s meds have been taken, and it's Monday night we've got a problem.

The other thing that medication adherence pack can really help with is, if there's an incident at the home and emergency responders have to come to the home, the medication adherence pack has all of the patient's medication information, doses, what types of drugs, et cetera, printed right there for those emergency responders to be able to understand what they're dealing with in terms of the medication regime that that patient who's having an emergency is on.

We're also now venturing into the world of the Internet of Things and connected packaging. Connected packaging will now allow us to know exactly when you have pierced a blister and accessed that medication—time of day, day of the week, [and] geolocation. In addition to that, through the use of instant messaging, we can provide reminders to patients in advance of an upcoming dose. We can also provide the patient or the caregiver with messages related to missed doses. Now we can pinpoint, with real accuracy, whether a patient has taken their dose or not. Overall, it's technology like this that’s really giving health care providers and the industry insights into dose-by-dose adherence.

Drug Topics®: What are the financial implications of medication nonadherence and how can multidose packaging specifically address or improve those?

Noye: As I stated earlier, 25% of hospital readmissions are the direct result of medication nonadherence. About 125,000 deaths in the United States each year can be attributed to the side effects and resultant effects of medication nonadherence. Furthermore, it's a $500 billion a year price tag to the United States health care industry for medication nonadherence. It is probably the single largest financial issue that the United States health care system faces, after dealing with the cost of drugs.

Multidose packaging can really help by providing the patient with that simple visual package of, here's what you need to take, [and] when, [along with] the quality assurance coming from the fact that a registered pharmacist has actually checked to ensure that every one of those cavities has the right number of pills and the right fills to ensure that the dosing regimen is exactly what that patient requires.

Drug Topics®: As the most accessible health care provider to much of the United States population, can you talk about the role of pharmacists in medication adherence management?

Noye: Absolutely. COVID-19 has really shown us the critical role that pharmacists play in the health care system, and that role is continuing to expand. Pharmacists are readily accessible and highly trusted by patients. Given that earlier statistic I talked about related to patient confusion about the medication regimes, the pharmacist really plays a critical role in bridging that gap. Pharmacists will take the time to explain the medication regime to the patient, including the dosing amounts and timing, potential side effects, and also, what a patient can expect over the course of that treatment regime. This is really the first step in improving adherence, and that is patient education.

Many pharmacists and pharmacies also offer what we call medication management programs, including 1 on 1 consultations. This allows the pharmacist to follow up directly with the patient and address any concerns that the patient may have, [such as] confusion related to the dosing regime itself; side effects that could be more severe than the than the physician had initially indicated; or in many…maintenance medication regimes, the fact that feeling better and feeling more stable is a direct result of staying on the medication regime, and the coaching back to the patient to stay on that maintenance medication regime and not self-medicate themselves off.

The other thing is patients, tend to see their pharmacists much more frequently than other health care providers. That really helps to bridge the accessibility gap. We know that approximately 90% of the US population lives within 5 miles of the pharmacy. As far as continuing to expand their reach into primary care services, this will help to strengthen that relationship between the pharmacist and patient.

Drug Topics®: What is the impact of multidose medication adherence packaging on pharmacist workflow and workload?

Noye: We know that any type of repackaging has workflow implications. However, what we've also seen in the last number of years—and the momentum is really growing across all of our markets—is what we call the implementation of centralized fulfillment and the automation that is included with centralized fulfillment.

What many pharmacies, whether they are chains, or one of the larger independents, have found is the filling of a prescription can be done very, very efficiently at scale. Enter the role of centralized fulfillment. Robots—whether they're blister filling machines, or pouch filling machines, or vial filling machines—can very quickly, effectively, and accurately fill prescriptions. What that does is allows the local pharmacies to interact with the central fulfillment centers to receive their scripts; those pharmacies can now spend more time on patient interactions. The speed at which centralized fulfillment and the automated filling technology can handle prescriptions is well in excess of what can be done manually at the storefront.

Also what we're seeing now is many of these automated systems are implementing visual checking systems. These visual checking systems are very, very sophisticated; in certain states, they are allowing pharmacists to move away from checking every individual pack to being able to do that on a sample basis, given how powerful some of these visual checking systems are.

Now, automation doesn't work for everybody, especially some of the smaller independent pharmacies. In that case, what we see the really progressive pharmacies doing is taking a really long hard look at the limited space they've got and organizing their workspace and their workflow to basically maximize their ability to fill prescriptions and check those prescriptions very, very accurately.

The other thing that we know is, when you when you think about what a medication adherence pack can do, there's a huge, huge safety element to it as well. Because a blister pack is filled by a pharmacy technician and checked by a registered pharmacist, you know that the patient is getting exactly what they need when they need it. There are over the counter products, [such as] little dosette boxes and other pill organizers that require the patient or the caregiver to take that myriad of vials in original pharmaceutical packaging, and then figure out what doses need to be put into what spots within those dosette boxes. That can, and does, create a real risk of error in terms of the wrong doses going in the wrong timeframes. We know categorically what the impacts of that can be.

Drug Topics®: Are there certain patients segments in particular who might benefit from the use of multidose medication packaging?

Noye: There certainly are. There are a number of different areas where it's very beneficial. First and foremost, it is for those patients who are on complex medication regimes. Traditionally, that also translates into older patients, especially those on 5 or more medications, where their dosing times are at multiple points over the course of the day. Also, for those with some level of basic cognitive impairment, a multidose medication adherence pack can really help those patients remember when to take what, or to help remind them that they haven't yet taken those doses.

There are a couple of other instances though where that can really help. Number one is what we call time and dose critical medications. In some hospital outpatient scenarios, taking the meds exactly at the right time is absolutely critical for recovery in a postoperative scenario. The other area where this can really benefit is in the case of high value drugs; oncology drugs are a great example here. Laying out what needs to be taken [and] when, with follow-up from the pharmacy to ensure that it's done, really does help those oncology patients on track. It's also an area—and we've done some pilot work—where connected packaging can help. The concept of reminder notices, the ability to track whether a patient has taken that 8:00 AM dose on time, allows the pharmacy to intervene—or allows a caregiver to intervene—in real time, rather than the very manual means of phoning Mom and trying to figure out if Mom has taken her meds today.

Drug Topics®: Across the industry, stakeholders are shifting towards a more green approach to doing business. In addition to reducing greenhouse gas emissions, what are some ways that Jones Healthcare is working towards creating a more sustainable footprint? How does multi dose packaging play into that goal?

Noye: What's really interesting to us, as we think about sustainability, is how important this now is to both our pharmacy customers and our patients. In fact, here in Canada, our largest Canadian customer has actually implemented incredibly aggressive deadlines for all of their packaging suppliers to get up to the bar on sustainability. For us, it's great to see the level of engagement that we're seeing for both our pharmacy customers as well as the patients.

We're doing a number of things, [for example,] circular design. We have been thinking about circular design; we have certainly amped that up substantially. We want to…get to fully circular products, and that is part of our roadmap.

One of the other tools that we're using extensively now is what we call a lifecycle assessment tool. What that does is, it allows us to track the environmental footprint and impact of packaging, from the earliest raw material, all the way through manufacturing into the patient's hands, and then what happens when that packaging has reached the end of its useful life. It allows us to really understand how we can reduce our environmental footprint across things like greenhouse gas emissions, carbon footprint, water usage, water eutrophication, et cetera, by making changes in the way we think about the packaging, the way we design it, [and] the materials that we use.

As part of this, we have recently launched a brand new blister made partially from the waste from sugarcane production. Molasses is a byproduct of sugarcane production, and for our bio PET blisters, one-third of their input PET actually comes from recycled molasses, which is fantastic.

And finally, we just launched our product sustainability roadmap. Our goal is to have a fully recyclable product portfolio by the end of 2025, which is a very, very aggressive goal. We're investigating myriad of options for design, materials, assembly, collection, and recycling. We're also partnering with a number of organizations and associations, such as the Sustainable Medicines Partnership and the Global Self-Care Federation, which allows us to really benefit from a broader set of resources and knowledge as we continue along our sustainability journey. At Jones, when we think about our products, we think about them along 3 different pillars: increased patient utility, sustainability, and design for automation. Sustainability is something that is really important to us.

Drug Topics®: Those are all the questions that I had for you, but are there any final thoughts or key takeaways that you'd like to discuss that we haven't covered?

Noye: There are 2 things. First and foremost, the issue of medication nonadherence is complex; there is no single bullet solution. What we found is that a collaborative approach to the problem involving all of the key stakeholders is really the only way to drive improvements. And we're really, really thankful for our pharmacy partners, our automation partners, [and] our industry association partners, as well as continuing to work directly with patients and physicians to really drive improvements in in medication adherence.

I really can't think of a more exciting time to be involved in this issue. Technology advancements are driving us to think differently about how we interact with patients. Pharmacy customers are properly prioritizing sustainability, which is really causing us to rethink our approach to design and manufacturing. Centralized fulfillment really requires us to understand how we can streamline the workflows, and it's all coming together to contribute to a brand new way of thinking. And for us, it's just an exhilarating time for our team here at Jones.

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