Optimizing Management of Schizophrenia with Long-acting Injectables - Episode 8

Patient Barriers to Long Acting Injectables for Schizophrenia Treatment

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Dr. Sanjai Rao and nurse practitioner Kimberly Garcia explain the barriers patients face in getting treatment with long-acting injectables and how COVID-19 has affected patient care.

Sanjai Rao, MD, DFAPA: You guys are an LAI [long-acting injectable]–heavy practice, and it sounds as if your state is very forward thinking in the way this stuff gets approached.

Kimberly Garcia, DNP, CRNP: Very forward thinking.

Sanjai Rao, MD, DFAPA: [It’s like that] where I work too. In the VA [Veterans Affairs] system, our barriers to getting LAIs are very minimal, and we’re encouraged to have as many people on LAIs as we possibly can. As you’ve looked around not just at your practice but elsewhere, what have you seen as some of the barriers to LAI adoption? And how do you get around those? How do we help people work with that?

Kimberly Garcia, DNP, CRNP: I think back to my years when I was working in inpatient and how we would have a patient who was rehospitalized several times and their symptoms very poorly managed. We’d get them established on a long-acting injectable and send them back out to the community only to have their local provider say, “I don’t give long-acting injectables, so I’m going to substitute and put you back on the same oral medication that was not working before.” One of the big frustrating points is inequitable access.

But what’s really interesting is that, especially in my area, some pharmacies have become extremely innovative. They’re willing to send an Uber to get a patient to come in for a long-acting injectable. They’ll go to the house to give the injection, looking at what’s available in the community, as well as what’s available in our own practice. Some of the barriers that I hear from other providers in psychiatry are, “We don’t have a Sharps box. We don’t have anyone comfortable giving the injection. I’m not comfortable even touching the patients.” If it’s an injection that needs to be given in the gluteal muscle, they don’t want to see that element of body. Good education or even a reminder. That’s OK—not every practice would need to accommodate but to be open to other options. Sometimes providers don’t want to prescribe something that they themselves would not administer, and I appreciate that, but I still think it’s a sometimes disservice to the patient.

Sanjai Rao, MD, DFAPA: Yeah. That highlights so many important things, and much of you talked about I categorize as system resistance.

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: There are inherent points of friction in our system of care that sometimes makes it difficult for patients to continue on LAIs even when they get started. Earlier on, we talked about patient resistance, how we might get around that, and the education we do. The 1 other thing I thought would be useful to highlight is clinician resistance, which you talked about and which I also think of as a by-product of how many of us were originally trained—this idea that LAIs are for the sickest people, and you don’t get there until later. The remnants of that training are still with us in a lot of ways.

Kimberly Garcia, DNP, CRNP: I agree.

Sanjai Rao, MD, DFAPA: Especially in the people who are making the decisions.

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: They’re all trained at a time when this was the case.

Transcript edited for clarity.