Hello and welcome. I'm Tristan Grindow, Deputy Medical Director and Director of Education for the American Psychiatric Association. I'm pleased that you are joining us for today's SMI Advisor webinar, Strategies for Success Using Lung Acting Injectable Medications. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need in caring for your patients. Now, I'd like to introduce you to today's faculty, Dr. Yvonne Yang. Dr. Yang is a board-certified psychiatrist trained in general adult psychiatry with a focus on psychosis. Since 2016, Dr. Yang has been the Director of the Psychosis Clinic and Acting Deputy Chief of the Psychosis Section at the West Los Angeles Veterans Affairs Medical Center. She is an Assistant Clinical Professor in Psychiatry at UCLA. Yvonne, thank you so much for joining us today and welcome back to SMI Advisor's webinar series. Thanks so much for the introduction, Tristan, and thank you so much to SMI Advisor, to the APA, and to SAMHSA for having me back. And thank you to all of you out there who are logged in and listening. I am really excited to be here to talk about lung acting injectables. And in general, my goal today is just to help you feel more comfortable with LAIs and to give you a sense that they're not the maybe rigid or scary treatment that we sometimes associate with them, but rather are quite flexible and, most importantly, oftentimes the best option for our patients. I have no disclosures of any kind. So there are four main sections today's talk. First of all, we'll talk about in what situations and what types of patients could benefit the most from having an LAI. There are some great resources that, before I found them, I had some difficulty knowing exactly what to do and what type of scenario with LAIs, and I want to share those with you, including a wonderful website created by SMI Advisor and available on SMI Advisor. We'll talk about some of the nitty-gritty of prescribing LAIs, including initiation, discontinuation, and missed doses. Lastly, and I will try to spend a significant portion of time on this, I'd like to talk about barriers, both real world and psychological, to use of long-acting injectable medications and, of course, practical strategies on how to overcome them. So, first of all, because you're here, you're probably aware of the benefits of long-acting injectables. I'm going to spend a very brief amount of time on some of what I think is the strongest literature in support of using long-acting injectable medication. So, first of all, I tried to assign a number, a general number, to at what point in time should I be considering an LAI for a patient with regards to their adherence. I make this statement, but hoping everybody will keep in mind that literature shows that for all patients, even those with just medical illnesses, not mental illnesses, have an average compliance of about 60% of their medication. So, even though I make this statement in history of our current medication adherence of less than 80%, for the most part, most patients aren't keeping a medication adherence of this rate. Comorbid substance use, difficulty keeping or maintaining a medication regimen. For instance, patients of ours who are homeless have difficulty sometimes maintaining their PO meds. They might get stolen with their backpack, or if somebody lives in a community living and they have a lot of roommates, that can also be difficult. There's plenty of evidence that LAIs should be strongly considered in new-onset psychosis in first-episode patients. I'll show you a data slide on that. Of course, some patients don't like having to think about taking a medication every day, and LAIs can be a good solution for them. Definitely, for patients who only partially respond to PO medications, many times if you transition a patient to an LAI of the same medication, they'll do better. This is one potential explanation for that, and I'll talk more about that, skipping first-pass metabolism, for instance. What exactly makes LAIs better? First of all, three main points. They decrease symptoms, they decrease rehospitalization rates, and they decrease mortality. I think these are all strong arguments for using LAIs over PO medications. First of all, this is a paper that came out of UCLA several years ago now, in which first-episode patients with psychosis were randomized to either oral risperidone or risperdal consta, actually, excuse me, long-acting injectable risperidone microspheres. Now, in the oral risperidone group, so this is a Kaplan-Meier curve, you can see over the course of one year, patients on oral risperidone relapsed at much higher rates than those on long-acting injectable risperidone. Also, I'd like to point out that the patients on oral risperidone, I think, were coming in either every week or every two weeks for visits with study staff, meaning they were probably in one of the very highest ranges of oral compliance that one could imagine your patients having in the outpatient world. And even so, there was still a really dramatic difference between the rates of relapse, symptomatic relapse. The next two slides are studies based on the Swedish cohort of almost 30,000 patients. This paper was published in 2017. The next slide on mortality was published in 2018. I think data from these large cohort studies are extremely valuable to our field, probably the strongest evidence we have, and especially in the case of examining agents like LAIs or, for instance, clozapine, which the last talk that I gave was on, and also referenced these studies. Randomized controlled trials are not going to capture the patient population that really needs these types of medications the most. Therefore, these large cohort studies, which I believe this one had a 14-year follow-up, and they also later in 2019 published another study with a 20-year follow-up, have really, really strong evidence and can suss out differences between agents. Strong evidence and can suss out differences between agents that randomized controlled trials can't. My main point of this slide is if we look, so as you can see here, they're organized in terms of the most likely to favor a specific antipsychotic to prevent rehospitalization during monotherapy with any of these agents. So they're organized in order of most effective to least effective. I'd like to point out that all of the top agents are, up until oral lanzapine and polytherapy, are either oral clozapine or LAIs. And then olanzapine, which many of us regard, of course, as the best oral antipsychotic, is a distant seventh or eighth on this list. Furthermore, long-acting injectables are associated with lower all-cause mortality. So not just psychiatric hospitalization, but all-cause mortality. Here, the y-axis, again, it's the Kaplan-Meier curve demonstrating each, you know, tiny tick that it decreases as an event. And the, let's see, the dotted green line is no antipsychotics. These two lines are actually the first-generation oral and LAIs. And then these two lines, the orange dotted line, is second-generation oral agents. And this pink dotted line is second-generation LAI agents. And that group has the lowest rates of all-cause mortality over the course of eight years. This was done, again, in the same cohort of almost 30,000 patients in Sweden. So what specifically about a long-acting injectable is different about oral medications? So, as I mentioned before, it avoids problems that can reduce oral bioavailability. It also helps avoid the peaks and troughs associated with oral medication. It reduces problems with nonadherence in part because patients have more consistent exposure to serum levels. However, and this should not be underestimated, patients on long-acting injectables also generally have more frequent contact with healthcare providers because they're coming in to get their shots. Even if it's a nurse or even if they're just going to a pharmacy that happens to be able to administer injections, they still have something every two weeks or every four weeks that causes them to take care of themselves and take care of their illness, which results in improvements in their care. So longer half-life decreases relapse even in the case of nonadherence. There is a great paper from Journal of Clinical Psychiatry in 2017 comparing oral paliperidone, which is this dark blue line, to one-month formulation paliperidone to the three-month formulation known as TRNSA, paliperidone. The half-lives here, I believe, for one-month paliperidone are between 30 and 45 days and for a three-month paliperidone is between 90 and 180 days depending on where you inject the medication, and I'll talk about different injection sites later in the talk. Generally, release is faster from the deltoid, so if you want a longer half-life, you choose the gluteal muscle, but as you can see, again, Kaplan-Meier curve, the rate of relapse on patients who discontinue their oral medication is much more rapid than those who discontinue paliperidone one-month formulation, which in turn is a much faster rate of relapse than those who are on the three-month formulation. So, now I'd like to talk about what I think can be a somewhat confusing topic because of the now increasingly large number of LAIs available to us, and I want to introduce a site. It's not really introducing. It's been around, I think, since at least last year, if not two years, but the SMI Advisor Long-Acting Injectable Center of Excellence. You can find it just by googling SMI Advisor LAI COE, or you can go to this link here, and what it does is it actually organizes a lot of the information I'm going to tell you into basically very digestible bits, and in addition to this, you can also request consultation from experts on the SMI Advisor site. I think it's most easiest to think about LAIs in terms of families. So, if we start with the second-generation agents, which still now are more common than first-generation agents, there's the risperidone, paliperidone family, right? So, of course, these can be grouped together because paliperidone is just the first metabolite of risperidone. The original, very first LAI of second generations was the two-week risperidol-constant risperidone microspheres injection. Slightly newer is paliperidone palmitate, the four-week formulation. Importantly, this agent, in theory, can be administered with two injections, two loading doses one week apart, which should eliminate the need for PO overlap, although I'm going to talk a little bit about PO overlap and making decisions about that later in the talk. Of course, there's also the 12-week formulation of paliperidone palmitate, known as Trinza, a terrific option and something I always try to tell patients as something they could look forward to. They wouldn't have to take any more oral medication, just one shot every three months, sounds pretty amazing. And the subcutaneous risperidone injection has just been FDA-approved, per seris. All right, so that's the risperidone family. The aripiprazole family is a little bit different. I think what makes the aripiprazole family a little bit more confusing is that there are two different pharmaceutical companies putting out agents, both of which are long-acting injectable forms of aripiprazole. So first of all, and at least here in Southern California, much more common than Aristata is Maitena, aripiprazole monohydrate. This is a four-week IM injection. Aristata can be given up to every six or even eight weeks, aripiprazole laroxil. Aristata is a little special because, like Imvegazistana, you can have two loading injections up to 10 days apart. The brand name for that injection is called Initio, and you can avoid PIA overlap using that. Now, in a family sort of by itself is the long-acting injectable form of olanzapine, of course, which is very rarely used here in the United States due to post-injection delirium sedation syndrome and the need to monitor for three hours in the office. I've included just a comment that based on personal communication of a visiting resident here in our psychosis clinic, we heard that many sites in Europe, they only monitor the very first injection and then not after that, which means that it's much more commonly used there than here. Let's not forget about the first-generation LAIs. There are really two being used here in the United States, halodaldecanoate, of course, and flufenazine decanoate. Many of our patients are on these agents, and they are a little bit in the class themselves. One thing that I think is really neat about these is that it's actually acceptable to transition from the IM formulation of one of these to the IM formulation of the other one using a direct conversion as opposed to having to stabilize the patient on oral medication first and then transition them to the LAI afterwards. So, let's talk about some general facts about long-acting injectables. So, because of their very long half-life, all LAIs take three to four months to reach a true steady state, meaning that excretion is the same as the initial metabolism. Most four-week injection formulations repeat levels within serum within five to 12 days of injection, depending on injection site, and stay in the bloodstream up to 150 days after a single injection, again, sort of supporting the argument that relapse is delayed in patients who get LAI medications. I mentioned before that the drug is absorbed more quickly from the deltoid site than the gluteal. This comes into play when trying to correct for things like missed doses. For instance, if a patient has missed a dose, in the case of paliperidone palmitate, it's recommended that their next dose be given in the deltoid rather than the gluteal muscle. However, with deltoid administration, peak-to-trough ratios are wider, of course, because of that faster absorption rate. Most LAIs can be administered in doses in those advertised. I want to clarify this statement because I'm going to make a similar statement later, which will sound a little confusing. What I mean by this is that some medications come preloaded in specific doses, like Invega, but others come in a vial that can be drawn at different doses. For instance, Abilify Maintaina is FDA-approved at a dose of 300 milligrams and 400 milligrams per injection. However, it is easy to administer a dose different than that and just ask your nurse to draw a slightly different volume into the syringe. That's also true, of course, of Haldol and flufenazine. Okay, so in terms of what are the different characteristics of each LAI class, so paliperidone palmitate four-week formulation, which is made by Janssen, with the initiation regimen of two injections one week apart, in theory, can avoid PO overlap, and elevations in prolactin are accompanied by sexual side effects often. Many people don't know this, but it's extremely important to note that this medication can be administered even every three weeks or every five weeks, depending on your patient's side effect or symptom burden. Really helpful if your patient's having breakthrough symptoms for the last week, for instance. The 12-week formulation is known as Trinza, and it's actually pretty straightforward to transition. So you can't put a patient on the 12-week formulation from PO. They have to transition to the four-week formulation first. They have to be on the four-week formulation for four months with the same dose for the last two months, establish clinical stability on that dose, and if you find it, then you can convert your patient to the 12-month formulation. And it's not just a matter of kind of tripling their dose of their four-week injection. There's a non-linear conversion, and that's provided by the manufacturer. In terms of Abilify, aripiprazole monohydrate, known as Maintaina, is made by Otsuka, and of course, despite what was sort of initially advertised when aripiprazole first came out, waking is a problem in some percentage of subjects. Of course, it is in paliperidone palmitate as well. Akathisia is a relatively common side effect. This medication is given every four weeks. There is flexibility with it as well, and they do advertise a PO overlap with a full dose for 14 days. Now, a different pharmaceutical company makes aripiprazole loraxil. This is a prodrug of aripiprazole. Similar side effects, however, it has dosing options for six weeks and ends Q8 weeks, and also they are now marketing a second injection that can be given within 10 days of the first injection, allowing patients and providers to avoid PO overlap. When considering second-generation LAIs versus first-generation LAIs, I think these concepts are fairly well understood in the field. Second-generation LAIs are, of course, associated with more weight gain compared to first-generation LAIs. However, EPS side effects and tardive dyskinesia are greater in patients with first-generation LAIs. However, I really don't want providers to forget about first-generation LAIs. For patients who weight gain and diabetes are a concern, first-generation LAIs can be excellent. Okay, the ever-complicated topic of PO overlap. I think this is a difficult topic because manufacturers actually provide very minimal guidance about how much PO overlap. They might say two weeks PO overlap or three weeks PO overlap, or they might provide no guidance as in the case of first-generation antipsychotics. It's a concern because I think for every clinician, nobody wants to see their patient decompensate and end up having to be rehospitalized or have a poor outcome because we're in the process of trying to transition them to an LAI. So, first of all, another resource that I want to make sure everybody is aware of is the FDA manufacturer's label, also known as package insert or drug label or drug insert, and also the SMI advisor LAI COE, which I just mentioned. So, these drug inserts have a tremendous amount of information and include more detailed information than you'll find anywhere else on transition to PO overlap. As I was saying, generally, two to three weeks of PO overlap at full oral deaths is recommended. However, and I would be interested to hear what other clinicians' experiences are out there, this represents a more or less not formally studied but certainly personally experienced data as a director of a clinic that sees patients with psychosis only that oftentimes more PO overlap is useful. For instance, if there's a high concern for relapse or rehospitalization, you could cut the dose in half and then continue for another one to three weeks. I have also seen patients benefit from a half dose, continued, a half PO dose continued for one to two weeks, even though they're on the initiation protocol of paliperidone palmitate, which in theory should eliminate the need for PO overlap. So my point here is that making that kind of decision is really a case-by-case basis, but I've found much more benefit from it. I have not found a lot of patients coming in with sort of intractable side effects. Okay, now onto the topic of missed or late doses. So this is from, again, so this is actually the FDA manufacturer label, the drug label, and I show this for several reasons. First of all, there's a table like this for every single package insert, which is incredibly helpful. However, it also is a lot of words, which is kind of annoying, but I think it's really important to be aware of where to find this information because I've had so many patients who missed their second dose, their initiation dose of paliperidone palmitate. So if it's less than four weeks since the first injection, they actually recommend a second initiation dose of 156 milligrams in the deltoid muscle as soon as possible, but they also recommend a third injection, oh, I'm sorry, a third injection of 117 milligrams in the deltoid or gluteal muscle, and then resume monthly dosing. An alternative to this is to provide 14 days of PO overlap and then resume monthly dosing. In the case of missed doses, if the dose is between zero to two weeks late, resuming monthly dosing is fine. Between six weeks and six months, basically administering another loading dose is recommended. Similarly, Abilify Maintainer, if it's only one week since their last dose, or excuse me, if they're only one week late for their next injection, just giving it to them as soon as possible is sufficient. However, if they've missed more than one week, they've missed their last injection for more than one week, the manufacturer recommends giving them an oral bridge for 14 days. So basically the strategy in the case of paliperidone is administering an injection as soon as possible in the case of a missed dose, and in the case of aripiprazole, the strategy is to administer an oral bridge as soon as possible for 14 days until they can get their next injection. However, one reason it's really important to make a reference to the product insert is that the instructions are slightly different if the missed dose is a second or third versus a fourth or subsequent. And of course, that's because by the time a patient has received their fourth or later dose, they will have reached steady state by that point. This is my one and only slide on side effects. And the reason is, side effects of LAIs have been shown to be essentially identical to PO medication. In a conversation with Keith Nuchterlein, who published the study on first episode psychosis patients who were on oral risperidone or the Q2 week risperidone microsphere injections, patients who were maintaining 100% compliance or adherence with their oral medication had the exact same clinical and side effect profile as patients who were receiving the LAI. I want to provide you with some strategies for how to handle persistent or breakthrough symptoms or even symptomatic relapse. There are actually quite a few options. For instance, let's say you have a patient For instance, let's say your patient has been successfully transitioned to an LAI. However, some of their auditory hallucinations or their paranoia return just during the last week before their next injection. There are lots of options to help here. For instance, their injections could be given every three weeks instead of every four weeks. Of course, their dose could be increased or decreased. Even though there is a particular dose range that has been approved by the FDA, we do have the flexibility to increase dose ranges above that on a case-by-case basis. This may be viewed differently by different groups. However, we've been very successful with offering the option of taking PO medications just for the last few days, for the last week, or sometimes, rarely, even on a PRN basis for patients who just have a slight increase in their symptoms right before they get their next shot. Another point that I have made previously in this talk, but I didn't add to this slide, is that if a patient is having breakthrough symptoms and is having their injection in their deltoid muscle, this is a good reason to switch to the gluteal muscle, which will basically lengthen the amount of time that they're exposed to the medication. So that would also be an option if the patient is willing to do that. Discontinuation is very simple. And the reason is that the half-life is so long, there's no need for any kind of taper or gradually increasing the interval between injections. The last injection can be given, let's say it's a four-week formulation, medication can be resumed at full dose on the next day their next injection would have been due. Okay, so this slide is a little bit about flexibility. Can I give higher or lower doses of LAIs than those, for instance, either advertised by a company or approved by the FDA? And the answer is yes. There definitely are certain LAIs that lower volumes can be injected for smaller doses. Multiple injections can be given for higher doses. Can I give any injection at shorter or longer intervals than those advertised? Again, yes. Almost all LAIs have this flexibility, especially given the wide variability in metabolism and clearance rate among individuals. LAIs should be tailored to meet the needs of individual patients, just like PO medications are, and LAIs can be. You should feel the confidence to do this. Can I give PO supplementation while on an LAI? Absolutely. I think this can be incredibly useful. Will some people think that it is a little bit messy or a little inelegant? Possibly, but what really matters is that your patients be successful in their life and of course in taking their medication. This is trying to address an anxiety that I think many of us have when we're first using long-acting injectables. Will I give my patients an intractable NMS or akathisia or orthostatic hypotension? Of course, the idea of an intractable akathisia that just didn't end is a really horrifying idea. However, in our clinic, we've just given thousands and thousands and thousands of injections, and this just doesn't happen. If a side effect does happen, it could be treated with the same agent that you would give somebody for a side effect of a PO medication, and it's effective. There's not a lot to guide us when it comes to choosing which of the panoply of long-acting injectable medications is available to us. In general, there is just like PO medication, well, that's not true, not just like PO medications. Certainly after the CADI study, there was an idea that no oral medication is necessarily superior to another. LAIs, there hasn't been a lot of evidence showing that one LAI medication is more effective than another, except one recent meta-analysis did demonstrate improved functional outcomes for patients on erypropasol LAI versus paliperidone LAI, and I recite that paper here, so you can look it up later if you'd like. We tend to focus on which PO medication is effective and has a few side effects for a patient and then transition them to the LAI. I also do like to, if a patient tells me they're interested in only having a shot every three months, I think that is a great option for them, and therefore, if they, trying them on a risperidone and trying to transition them then to paliperidone four weeks formulation and then to 12 week can be just a really great thing. Of course, the erypropasol Aristata now has an eight week injection interval, which will be great for patients who do well on erypropasol. Okay. Finally, let's talk about barriers to using LAIs, and I grouped these into three main categories. First of all, barriers in the healthcare system itself, which are very real. Barriers on the part of the patient, also something we come up against all the time, and then barriers within ourselves, the providers. So this is a huge problem. This is actually not a problem I encounter myself very often where I practice clinically at the VA, but in general, sometimes it can be difficult to get an insurance company, especially a private insurance company to pay for a long-acting injectable. It can be hundreds of dollars a month. It can look like a lot to them. And then equally problematic, many private practitioners don't have a nurse associated with their clinic and may not feel comfortable administering a long-acting injectable medication themselves. The barriers for patients are many. Many patients tell me they're afraid of needles. They don't like having shots. They don't like the pain associated with getting a shot. I think psychologically, there can be a real sense of loss of control, right? If a patient is on a PO medication, they can kind of do whatever they want. They can just choose not to take it one day. They can just choose to stop taking it any time, as many of us know well. I think societally and culturally, there's certainly a certain amount of stigma associated with being given an injection. There's sometimes a sense of punishment or worry about feeling coerced because they're receiving a shot. It's something being done to them. Perhaps patients worry about this stigma, worry about what others will think it means if they receive a shot every month. And of course, patients then worry about paying for long-acting injectable medications. Some patients say they actually don't want to have to come to the clinic every month or every two weeks. So lastly, physicians, prescribers. I think the biggest barrier to prescribing long-acting injectables is unfamiliarity. However, I think that we all carry the societal stigma about injections and about needles along within ourselves, just as it's present within our society. All of us want the best for our patients. None of us want to give our patients a sense that we're forcing them to do something or that they don't have a choice. And injections are associated with that in our society. We don't like the idea of our patients having a shot every month. We don't like the idea of them having pain. I think sometimes there's a concern when the topic is broached with the patient that they'll think, oh, you want me to do this because you don't trust me to take my own medication. And that presents a bit of a conflict for physicians and prescribers. There can actually be a feeling of loss of control on the part of the physician when prescribing an LAI to a patient because I think in our minds, PO medication has a great deal of flexibility. We can change agents very easily, reduce or increase dosing easily. And it seems like it might be more difficult with long-acting injectables. I hope I've helped address that just a little bit. And then as I mentioned, as part of the problem within the healthcare system, finding someone or somewhere to do the injection is a real challenge. And of course, being on the phone for hours trying to field a prior authorization is not a way anybody wants to spend their time. Okay, so strategy for success number one, healthcare system. I'm really happy to be able to share some of these tips with the audience today. Surprisingly, well, maybe this isn't so surprising. Pharmaceutical companies themselves actually want to get insurance companies to pay for LAIs. So pharmaceutical companies actually have their own units whose only reason for existence is to convince insurance companies to get their medications paid for. So they actually have, I don't think I put it here. So pharmaceutical companies actually have different card programs that can make LAIs free or much reduced price, $10 or $30 an injection for patients if you're eligible. They will also sometimes interface directly with the patient's insurance company on your behalf to convince them to prescribe and to cover a medication for a patient. There are specific pharmacy programs that have experience with getting LAIs authorized as well. For instance, Vons and Albertsons. Oh, I just mentioned this, the savings card programs that are offered by pharmaceutical companies. And if you're having trouble getting an insurance company to cover initiation of an LAI in order to demonstrate efficacy, utilize free samples, even if you have to talk to your local pharma rep. If you're on the phone undergoing a prior authorization process, have a discussion about how long-acting injectables will keep your patient out of the hospital and save that company money in the long run. In terms of infrastructure, there are actually some great solutions. Many pharmacies actually have pharmacists or nurses who can administer injections, including at CVS Pharmacy. And of course, all of us can do injections ourselves. In our clinic, it's a priority that every resident who comes through here administers at least one LAI before they leave the clinic, if not many, many more. And every package insert has these extensive drawings and diagrams, and really, you can't mess it up. All right, strategy for success number two, the patient. So if your patient doesn't like needles, I like to offer Trinza, which is once every three months. If your patient has pain at the injection site, consider a gluteal injection that's often less painful because it's a larger muscle to absorb the volume of the injection. They can also ice before the injection. In terms of the stigma associated with needles and injections, I think it's helpful to remind patients that more medications are being given as injections, for instance, for rheumatoid arthritis or osteoporosis. And in other countries, injectable medications are actually first line. More importantly, just remind patients that the LAI is going to be more effective than PO medication, and that's relevant to this fear of loss of control. LAIs give patients the best possible control over their illness, and they need to be told this to help them feel confident in the medication. At the same time, be available to them during the transition, helping them to manage side effects, and you can change dosing and interval as needed, just like with PO medications. Strategy for success number three, the prescriber. Most of you in the audience are in this category, and of course, primarily, you need to educate yourself. And look, you've already taken a wonderful step. You're here at this webinar. Utilize resources such as up-to-date, package inserts, and I should have put here SMI Advisor. The LAI Center of Excellence has a great deal of information, beautifully summarized, really fantastic website. I highly recommend it. I said this at the end of my Clozapine talk, which was that the best way to become comfortable with Clozapine is to prescribe Clozapine. Similarly, the best way to overcome your reservations or your anxiety about using long-acting injectables is just to start using a long-acting injectable. This is part of being a physician in a tough healthcare system in which to work, but finding the community that supports you and that supports your patients. There are pharmacies out there that are experienced with getting LAIs paid for and administered. They will have a nurse in-house to give a shot. They will talk to the insurance company. They will have tricks up their sleeve for how to get insurance companies to cover their injections. I think the Vons Albertson's tip is a really great one, at least here in Southern California. Definitely become comfortable with giving LAIs. Let's say that you have a nurse you often rely on, but they're not there one day. Definitely give yourself the option at least to be a backup. And then lastly, give your patients the opportunity to surprise you. I think many of us make assumptions about our patients. We assume they're not going to want a shot. We assume they won't want the pain associated with it. They won't want to give up the control. However, many patients will say, if this is going to help me feel better, then let's try it. If this is going to mean I don't take this medication every single night, then let's try it. Okay, so the take-home messages of today's talk are that long-acting injectable medications improve mortality, symptoms, and outcomes. I highly recommend using the SMI Advisor Long-Acting Injectable Center of Excellence along with some of the other materials that I mentioned, including package inserts, also known as FDA medication labels, which are available through the SMI Advisor site. Oh, here, I just said that. And overcome barriers to LAI use by working directly with pharmaceutical companies. It's a little counterintuitive, but that can be very helpful in this case. Becoming more comfortable with LAIs and letting your patients know that LAIs give them the most control over their illness. Here are some references available to you at your leisure, and thank you very much.

Dr. Yvonne Yang

long-acting injectable medications

serious mental illness

improve adherence

reduce rehospitalization rates

risperidone

aripiprazole

SMI Advisor Long-Acting Injectable Center of Excellence