Optimizing Management of Schizophrenia with Long-acting Injectables - Episode 5

Discussing Long Acting Injectables for Schizophrenia with Patients

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Sanjai Rao, MD, DFAPA, starts a conversation on how to discuss long acting injectables with patients and how to best transition from an oral medication.

Sanjai Rao, MD, DFAPA: Do you talk to them the first time you see them, the second time you see them? When do you get this going?

Kimberly Garcia, DNP, CRNP: Typically, as we’re new into treatment, listening, we’re going over their history. Typically they’ve been in the hospital already by the time they reach me in the outpatient practice. I’ll sometimes ask them, “What are some of your goals? Where would you like to see yourself 5 or 10 years from now?” Then what I’ll typically do is start the conversation and then follow through at subsequent visits. I usually leave a little information.

I will say to them, “One thing you may want to consider, we have a number of injectable products,” and they’ll say, “Injection?” I say, “My gosh, no, it’s not bad at all. It’s very well tolerated. We do many of them here.” I usually will use patient experiences. For some of my patients, they prefer to give me the responsibility of worrying about their medication regimen, so they don’t have to worry about anything. We can take care of having the pharmacy deliver the injection. Patients come in, depending on the product, in 1 to 3 months, now even up to 6 months. We have some patients with that, and it’s exciting if we present this as an opportunity for them.

Where I am in Pennsylvania, the state does not require prior authorizations for long-acting injectables [LAIs]. They want us to use them early and they want us to not experience any barriers to their use. Sometimes we have to educate patients about the reason for that and what that could mean for them and their illness over time. What I find is that, especially if they bring another family member or friend with them or an affiliate, even like a caseworker, for them to hear this information. I don’t push because as soon as we start pushing, there are psychological implications for that. So we just provide them with the information, letting them know that this is an option. We offer this service. If you’d like to take advantage, you could. How interesting it is that often at that next appointment with me, they’ll say, “Could you tell me a little more about that injection? Or “I was looking up information about the injection, and I might be interested in that.”

Sanjai Rao, MD, DFAPA: It’s wonderful. You’re applying a motivational enhancement, motivational interviewing approach where you’re exploring it with them, giving them some options, reinforcing them when they come back with a positive impression of it and want to pursue it more. It’s often enticing them to want to come back and ask for it and increasing their investment in it. I love that. I’ve never heard this approach before, where some patients like us to handle all this stuff for them. If you’d like us to handle all this, we can do that. What a way of portraying the benefit of being on an injection: no, let us take care of it. All you have to do is arrive.

Kimberly Garcia, DNP, CRNP: And they love it.

Sanjai Rao, MD, DFAPA: And we’ll handle the rest.

Kimberly Garcia, DNP, CRNP: At the end of the day that’s what it’s about. To say to a patient, “Bring me your arm, and that’s the expectation for today’s appointment.” It’s amazing. Injectables were sometimes portrayed in a very negative light, as a treatment of last resort. We’ve flipped that to present this, as I call it, an opportunity. “I have a nice opportunity if you’re interested,” and that’s a lot of the way that I will even talk about it: as an opportunity.

Sanjai Rao, MD, DFAPA: That’s great. I often will try to figure out what part of the LAI experience would be beneficial to them. Are they someone who travels and leaves their meds behind? Someone who wants the freedom not to have to go home and get their med bottle when they need something? Someone who lives with someone and wants some privacy and they doesn’t want a medication bottle lying around? Or are they homeless and keep getting their meds stolen? Whatever their particular experience is, show them that if they were on the monthly injection or a longer duration injection, they wouldn’t have to deal with whatever this problem is that makes it hard to be on oral medications.

Kimberly Garcia, DNP, CRNP: Absolutely. I have many patients who are from the Dominican Republic. My patients will oftentimes go for several months at a time back to their country. We know that insurances don’t like to provide a large amount of medication at once, so it’s created a number of barriers for them. Either they’ve had to rely on family members to mail them medications, which is always tricky, or they’ve tried to get equivalent medications or semiequivalent medications in their home country. For them, to get 1 of the longer-acting injectables has been a huge benefit.

Transcript edited for clarity.