Long-acting medications (LAMs) are most often utilized as a strategy to address medication non-adherence; however, research supports the use of LAMs as first-tier medications. This guide is a call to action for increasing the safe and appropriate use of LAMs.
This publication was supported in part by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents are solely the responsibility or private funding was used to support development of this publication.
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.
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.
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:
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
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.
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.”
To make informed decisions, patients must be educated about the potential risks and benefits of oral vs. injectable medications.
Resources for Discussing LAMs with Patients
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.
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:
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.
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
The American Association of Psychiatric Pharmacists’ complimentary training program on LAIs provides information and guidance on appropriate patient selection, LAI preparation and administration techniques and insights into methods to engage a patient population with serious mental illness.
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