Guide to Long-acting Medications

A First-line Treatment Option for Patients

Drawing upon clinical guidance developed by the American Association of Community Psychiatrists and research evidence from the National Institute for Mental Health and others, the National Council for Mental Wellbeing believes that all community mental health providers should provide LAMs as a first-line treatment option to patients and encourages its members to increase and support the safe and effective use of LAMs.

Currently, LAMs are most often utilized as a strategy to address medication non-adherence; however, research supports the use of LAMs as first tier medications, not just as a second or third tier approach.

Organizations Should Play an Active Role

Although targeted to psychiatrists and other clinicians, these recommendations require that organizations play an active role in establishing systems to support staff, patients and families with information and education about the safe and effective use of LAMs and the infrastructure, policies and procedures needed to deliver this method of treatment.

It is further recommended that organizations establish a continuous quality improvement (CQI) process to make necessary improvements that will increase patient understanding of and access to LAMs. Collecting, analyzing and using data is critical to monitoring progress and guiding the change process.

LAMs are widely available and have research-proven clinical benefits compared to oral medications for individuals with schizophrenia, schizoaffective disorder or bipolar disorder. These include a significant delay and reduction in relapse, particularly in patients with early-phase or first-episode schizophrenia and a lower risk of discontinuation and frequency of hospitalizations compared with oral antipsychotics.

Despite the evidence, LAMs are underutilized and only 15 to 28 percent of eligible patients with schizophrenia in the U.S. receive them. As a treatment option, they are often reserved for patients who are non-adherent to oral medications, have experienced multiple relapses or have expressed a preference for LAMs. However, recent evidence and guidance support recommending LAMs over oral medications to all eligible patients as a better treatment option. Using LAMs is an effective prevention strategy for future non-adherence and relapse/deterioration. LAMs also simplify the treatment regimen and reduce patient medication-taking burden.

The benefits of LAMs go beyond increasing medication adherence, particularly for those in the early stages of illness as they may better address a variety of clinical and social challenges. The National Council recommends them for all patients as a better choice than oral medication and encourages providers to utilize long-acting medications as an early treatment option to prevent negative outcomes rather than using them only after multiple negative outcomes such as failed oral medications, multiple relapses or hospitalizations.

When should providers prescribe LAMs?

Providers should have established processes for assessing non-adherence to medications. For patients who are identified as non-adherent, providers should work with the individual to determine if long-acting medications are the right option for them.

Providers should consider prescribing LAMs for:

• Patients who may be at high risk for non-adherence to medications. Patients who experience high utilization of emergency departments, unstable living conditions, co-occurring substance use, cognitive challenges, Anosognosia or limited insight.
• Patients involved in transitions of care. Patients being discharged from psychiatric hospitals, residential programs or leaving jail or prison.
• Patients demonstrating challenges with adherence: Past history of non-adherence to oral medications, challenges remembering to take medications as prescribed, or mis-placing medications.
• Patients seeking to relieve the burden of medication-taking. Patients who experience frustration or challenges with regimens associated with taking pills, sometimes 2 to 3 times a day as well as the associated frequency of visits to the physician and pharmacy.
• Patients experiencing first episode psychosis. This is an optimal time to educate patients and families about LAMs as they have the potential to reduce the rate of relapse thereby mitigating further impact on the brain and functioning.
• Patients who indicate using a LAM as their personal preference. This requires access to education by multiple staff, including Peer Coaches and availability of informational brochures and videos.

Support Recovery

The concept of recovery emphasizes resilience and control over problems and life. Rather than just treating or managing symptoms, it focuses on building resilience in people with mental illness and supporting those in emotional distress. Recovery looks beyond a person’s mental health problems to help them recognize their abilities and interests and support them as they achieve their own goals, aspirations and dreams. The process of engagement and promoting resilience and recovery is strongly linked to social inclusion. Supporting people as they regain their place in the communities, take part in mainstream activities and utilize opportunities for growth along with everyone else is a key role for mental health and social services.

From a recovery perspective, the use of LAMs should not just be viewed as a tool for preventing relapse, but as a resource to help patients work toward their own recovery goals. The process of recovery is highly personal and occurs via many pathways and hope and healing can only occur within a strong therapeutic relationship; therefore, providers should work toward empowering individuals to identify the treatment approaches that will lead achieving their personal goals. This could be as simple as offering education and information on all treatment options, including LAMs, early in the treatment process rather than as a secondary option.

Recovery Resources

• The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Treatment Improvement Protocol
• Recovery-oriented Systems of Care Resource Guide
• Recovery Model of Mental Illness: A Complementary Approach to Psychiatric Care
• Wellness Recovery Action Planning (WRAP): A program to facilitate recovery.
• Developing Recovery Enhancing Environments Measure (DREEM): An outcome measure and research tool to see how “recovery-oriented” a service is and gather information about mental health recovery from people who use mental health services.
• Recovery Star: A tool that allows people with mental health conditions who are using services to measure their own recovery progress.
• Checklist of Good Practice: Views of service users from both dominant and marginalized communities.

Employ a Trauma-Informed Approach

More than 90 percent of people who experience mental health, substance use conditions and homelessness have a history of trauma. Individuals with a history of trauma and/or coercive intramuscular injection medication may be at risk for trauma-related symptoms triggered by LAM administration or discussion. This can be addressed by establishing a trusting relationship and highlighting choice and preference for LAMs where there may have been little choice involved in intramuscular injection medications for agitation. In a trauma-Informed approach, one asks, “What happened to you?” rather than, “What is wrong with you?”

Before administering the first and subsequent injections, employ a trauma-informed approach by providing information, choice and empowerment.

• Offer a step-by-step description of what the process entails and what it may feel like.
• Allow the individual to choose the spot or arm for the injection site.
• Inquire about the person’s preference regarding having a family member or other person join them in the room for support.
• Ask if there is anything else that can be done to make them feel more comfortable.

Communicate Effectively and Empower Patients

Talking to patients about LAMs does not have to be uncomfortable for the patient or practitioner. Use of approaches such as shared decision-making and motivational interviewing can promote effective communication, collaboration, choice and empowerment.

Employ shared decision-making and motivational interviewing strategies throughout the course of care to help patients make meaningful treatment decisions, feel more empowered to make decisions about their care and experience the clinician as a recovery partner.

Shared decision-making approaches may include exploring treatment options like oral antipsychotic medications, psychosocial treatment only or LAMs when clinically indicated. When sensitively guided by the clinician, this process provides an important foundation to make self-directed medication decisions about LAMs.

Motivational engagement strategies like motivational interviewing can be implemented when the clinician identifies clear benefits of LAMs and the person is not yet ready to accept a trial of this treatment. If there is an involved family member or a supportive person in their social network, it is important to include them in constructively assisting the patient with decision-making regarding LAMs, particularly as an important tool in support of the person’s recovery goals.

Use language that is less frightening and stigmatizing by referring to LAMs as long-acting medications rather than “the IM” for intramuscular injection, long-acting injectables or “the needle.”

Educate and Involve Patients

To make informed decisions, patients must be educated about the potential risks and benefits of oral vs. injectable medications.

• Use shared decision-making and motivational interviewing strategies to promote effective communication, empowerment and collaboration.
• Develop a collaborative treatment plan.
• Have patient education brochures, videos, infographics and posters available that reflect the patients’ language and contribute to increased knowledge and decision-making.

Resources for Discussing LAMs with Patients

• A discussion guide that helps patients think through potential questions, concerns and options for long-acting medications.
• Video testimonials of patients who are using long-acting medications.
• Patient brochures, included in the Selected Long-acting Antipsychotic Medications table.

Involve Family and Caregivers

Family members can play an important role in the treatment planning and recovery process. Involving families, other members of the patient’s support network or a peer recovery coach in care begins with finding out who, if anyone, is included in their social support network. The patient or staff person should then reach out to that person to invite them to join one or more visits with the patient present. In addition to addressing mental health literacy, the identified support person will need education about the risks and benefits of long-acting medications and how they can provide support in a way that works for the patient. Culturally appropriate informational brochures on potential risks and benefits of LAMs should be available for family members.

Best Practices in Initiating LAMs

Start early.

Initiate discussion about LAMs as the preferred treatment option early in the treatment process and consider a possible long-term LAM transition plan when you begin administering oral medications. Key scenarios or decision points when prescribers should consider introducing long-acting medications as a treatment option include newly diagnosed patients, patients with a recent relapse or patients transitioning from in-patient care or incarceration.

Convey a clear, optimistic message.

When discussing the recommendation to choose a LAM, use the following approaches:

• Introduce the option as a “long-acting medication” formulation. Do not start by describing it as an injection. Present the advantages compared to oral medication first:
  • Fewer side-effects.
  • More effective in reducing symptoms (do not say “control” symptoms).
  • Smoother action – don’t feel it “kicking in” or fading away.
  • Decreased risk of hospitalization.
  • Addresses the challenge of having to remember to take a daily pill.
  • Reduces the total amount of medication taken compared to oral medication.
• Inform the patient that the frequency of injections is once per month or less and compare this experience to taking a vitamin B-12 or Depo-Provera (for female birth control) injection and ask for questions.
• Directly recommend starting a LAM based on your belief that it will be the most effective treatment approach.
• Consider letting the patient know that this form of medication, “is more expensive for Medicaid/Medicare/insurer but you deserve the best treatment available and we will work hard to get it for you.”

Start with a trial of oral medications.

For those who are not already taking an oral antipsychotic medication, a brief trial of oral medications for one week to one month is recommended to identify severe adverse reactions, response, dosing and/or ability to tolerate the agent. Prescribers can also use this tip sheet on choosing an LAI antipsychotic agent.

Start low and go slow.

Consider under-dosing the LAM at the beginning, rather than risk prolonged side-effects that may lead the person to refuse further LAM administrations. Use this recommended starting dosage tip sheet.

Transition with oral medications.

When starting a LAM, continue prescribing the oral antipsychotic medication the patient is already taking during the initiation period, when clinically indicated, and allow for flexible dosage adjustment to compensate for initial over- or under-dosing.

Maintain needed oral medications for extrapyramidal symptoms.

Individuals prescribed oral antipsychotic and anti-EPS medications who start on a LAM may be at risk for EPS due to nonadherence of oral anti-EPS medications. Educate patients receiving LAMs about the importance of taking anti-EPS medications even if they are not taking oral antipsychotic medications. Use of a symptom rating scale is also recommended.

Taper extrapyramidal symptoms medications.

Some patients who required treatment for EPS on oral medications may no longer need it after switching to a LAM. Other individuals may do well on lower anti-EPS dosing than with oral medication after transition to a LAM. Consider a slow taper of EPS medication after doing well on LAM for several months.

Use dosage conversion tables.

Reference the Selected Long-acting Antipsychotic Medications table.

Improve access.

Providers can improve access to LAMs by developing the capacity to administer LAMs themselves based on their trusting relationship with the patient, hiring trained nurses to administer LAMs or training their own nursing staff in the safe and effective administration of LAMs. Access can be greatly increased by providing outreach services: in-home injections. Organizations may also consider partnering with pharmacy services that can administer LAMs onsite. This can be accomplished through co-location or cooperative agreements with local pharmacies. Another option is to consult with the patient’s primary care provider to see if the nursing staff can provide LAM injections for your shared patients.

Best Practices in Monitoring LAMs

Check Plasma Levels

For those who are experiencing a suboptimal response, consider checking plasma levels of antipsychotic medications. This is advantageous when therapeutic ranges are known (e.g., haloperidol) and to identify rapid metabolizers (e.g., fluphenazine, risperidone or paliperidone) which can lead to better results after adjusting dosage and/or interval accordingly.

Anticipate Benefits From More Consistent Plasma Levels

Individuals at risk of antipsychotic discontinuation syndrome due to abrupt cessation of oral antipsychotics often experience clinical benefits from a LAM. Many patients have fewer side-effects due to avoiding the higher plasma medication concentration peaks associated with oral absorption.

Consider Contraindications

• Deep intramuscular injectable LAMs are contraindicated if the patient needs significant anticoagulation agents for other medical conditions to avoid the risk of internal bleeding or large hematomas.
• Needle phobia is another consideration. This may be addressed with Cognitive Behavioral Therapy (see 2017-2018 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults, pp. 41-46).

Educate All Staff

• Educate all staff on the potential benefits of LAMs and how to talk to patients and families about them. Prescribers, therapists, case managers, peer specialists and nurses should all regularly discuss medication adherence and the benefits of LAMs with their patients. The National Council’s Value Based Care Resource Library has tip sheets, case studies and guidance documents to educate staff as part of its Prescriber Toolkit.
• Peer specialists who have lived experience with LAMs can be effective advocates and support for LAM utilization and education and information shared by them is particularly valuable. Strive to include peers on treatment teams.
• Train providers and nursing staff proper administration techniques to ensure the safety and effectiveness of LAMs and to minimize discomfort to patients. Review Z-Track technique, needle stick safety, proper anatomical locations and aseptic administration.
• Ensure that all staff are trained in effective communication and engagement strategies including Motivational Interviewing and Shared Decision Making.

Prevent Missed Appointments

• Offer in-home administration of injections and/or transportation to injection sites.
• Involve family members/other partners in care.
• Involve peer support specialists or recovery coaches in care.
• Provide telephone reminders about appointments for LAMs.
• Provide LAM reminder cards to individuals upon administration so they know – and can track – their last LAM date and next LAM date. This minimizes the risk of early or redundant LAM administration by another provider and often increases individuals’ participation in the LAM process.

Ensure Safety and Effectiveness

• Identify a safe, private space for medication administration.
• Have appropriate supplies on hand such as safety/retracting needles, gauze, alcohol, Band-Aids and gloves.
• Arrange for refrigeration if Risperdal Consta is to be used.
• Develop a system for sharps and hazardous waste disposal.

Address Potential Barriers

• Utilize assistance programs, provided by many pharmaceutical companies, to support patients and providers in navigating coverage and cost of LAMs. The Desk Guide for Obtaining Coverage is a useful resource for staff responsible for supporting patients’ access to LAMs.
• Prevent negative patient perception of LAMs through education, use of sensitive language and effective communication and decision-making strategies.
• Overcome stigma associated with injections through patient and family education, brochures, posters and use of destigmatizing language.
• Improve provider knowledge of or experience with LAMs through practitioner education and organizational supports, policies and practices.
• Address staff and infrastructure barriers through updates to organizational environments, policies and procedures, including having a nurse or pharmacist handle pharmacy payment assistance needs, providing transportation to injection appointments and involving peer specialists with LAM experience on the treatment team as educators.
• Implement a tracking system or registry to ensure that patients are monitored for signs of medication non-adherence or partial adherence such as hospital admissions, ED visits and unexpected symptom recurrence. Ensure that flagged patients receive a recommendation for LAMs.

Institute Policies and Procedures

• Create a formal procedure for LAM orders to be communicated if the non-prescribing clinician or more than one clinician may be administering LAMs. Update orders through an electronic health record (EHR) when feasible.
• Create or update a bloodborne pathogen exposure policy in case of needlestick.
• Update formulary to include LAMs and clozapine.
• Create additional policies and procedures that support the safe and effective use of LAMs, such as the standard operating procedure created by Black Country Partnership NHS.

Collect, Analyze and Utilize Data

• Implement systems to continuously collect, analyze and utilize data on the rates of LAM utilization by individual clinicians.
• Clinicians, as a group, should review and discuss their individual variation in utilization of LAMs periodically.
• Collect, analyze and utilize data that demonstrates patient improvements in care such as progress toward recovery goals, reductions in utilization (such as hospitalizations, emergency departments), or advances in levels of care, such as AACP’s Levels of Care Utilization System for Psychiatric and Addiction Services.