By Jerry McKee, PharmD, MS, BCPP
- National Council Medical Directors Institute Position Paper
There are many patients with serious mental illness and substance use disorder who may benefit from a long-acting medication but are not offered a trial. Long-acting medications (LAMs) have been underutilized for these conditions, despite convincing evidence of their superior outcomes compared to oral medications.
It is reasonable to ask why this is the case, and what we can do to remove barriers and challenge our colleagues to improve performance in this arena.
The National Council on Mental Wellbeing’s Medical Director Institute took up this dilemma and convened an expert panel of psychiatrists, pharmacists, nurses, and representatives from the pharmaceutical industry in January 2025 to address the question of “Why does long-acting medication use range from 5% to 30% across states?” I represented AAPP on the panel while Ray Love, Pharm.D., BCPP represented the National Association of State Mental Health Program Directors (NASMHPD).
The result is the recently released position paper “Improving Utilization of Long-acting Medications: Toward Standardized Measures”. It is the hope that this document will begin to bend the curve towards increased appropriate use of long-acting medications
The paper suggests that the barrier is not clinical, but an issue of systemic barriers. Without standardized measures, providers lack the visibility to know where they stand and how to improve. Under the premise that “what is measured gets done”, this report provides the first-ever standardized performance benchmarks that make practice patterns visible and drive systematic improvement. Benchmark measures are established for initiation and maintenance of long-acting medications for SPMI, opioid use disorder, and alcohol use disorder. It is noted that not only do many patients never have a long-acting medication trial initiated, but there is a significant drop-out rate between first and subsequent follow-up doses, again a systemic issue often related to transitions of care hand-offs.
The thrust of this report is directed at a broad audience, including clinicians, quality improvement teams who work with patients with psychotic disorders, bipolar disorder, opioid use disorder and alcohol use disorder, as well as policy makers and administrators responsible for behavioral health care delivery systems, including Medicaid and Medicare authorities, managed care organizations and pharmacy benefit management organizations.
One of the recommendations brought forward by Drs. Love and McKee is collaboration between psychiatric professionals and community pharmacists to manage patients receiving long-acting medications as a method to remove a number of the systemic/administrative barriers to use of these tools. In 49 of 50 states, pharmacists may now administer these medications. While reimbursement for this service continues to be an issue in many areas, this is one avenue to streamline the medication administration and patient management aspect of care, in a time with increasing use of telehealth and where pharmacies remain fixed, brick and mortar institutions.