Overcoming the Misconceptions and Barriers of Long-acting Injectables (LAIs)

Dr. Rebecca Roma is the Chief Medical Officer at REACH, LLC, and an adjunct faculty member at the University of Pittsburgh School of Medicine. She is board-certified in Adult Psychiatry and currently provides psychiatric evaluations, medication management, and supportive therapy for mentally ill homeless patients at the Bethlehem Haven 902 Clinic in Pittsburgh.

In my practice, I frequently encounter the complexities of treating patients living with schizophrenia and bipolar I disorder. I want to share insights on how long-acting injectable (LAI) antipsychotics may potentially improve care for these patients, while addressing some common misconceptions that may hinder their use. 

Let’s discuss some of the common misconceptions surrounding the use of LAI antipsychotics.¹

Misconception 1: “My patient probably doesn’t want an injectable.”

This misconception may come from ambivalence among clinicians about offering LAI antipsychotics. Such reluctance may lead providers to shy away from recommending LAIs or fail to discuss them holistically with patients.² The conversation about LAIs should include the method of administration, the benefits, and the risks, and should address any questions from the patient. With this conversation, a patient can be well-informed and work with their healthcare provider on deciding what treatment option works best for them. LAIs are not a last resort or a punitive measure, but an option patients and clinicians can discuss as a treatment.

When fully informed about LAIs, some patients may prefer treatment with them.³ One potential reason is that LAIs have a longer dosing interval—from a couple of weeks to monthly to possibly even longer. A reduction in daily medication burden may lessen the patients’ reminder of their disease.⁴

It’s important to recognize that discussing LAIs with patients should not be a one-time conversation.² Patients’ treatment preferences and needs can evolve. By periodically revisiting the treatment conversation, clinicians can provide patients with ongoing education and reassurance, helping them make informed decisions based on the most current data and their personal experiences with their disorder.

Providers should encourage open, proactive dialogue with their patients that extends beyond the initial discussion. This approach allows the patient to reflect on their treatment options and provides multiple opportunities to address any emerging concerns or questions they might have.

Misconception 2: “LAIs are usually reserved for a last-resort treatment option.”

Recent schizophrenia guidelines suggest the potential usefulness of having earlier discussion about LAIs with patients at risk of nonadherence due to limited awareness of needing treatment or those with comorbid substance abuse.³

Although LAIs are generally recommended for patients who prefer an LAI or those who are treatment nonadherent, some newer guidelines recommend second-generation antipsychotic LAIs as a first-choice treatment option for schizophrenia, as well as maintenance treatment for bipolar I disorder.⁵

Misconception 3: “LAIs don’t seem as safe as oral antipsychotics.”

In my opinion, the roots of this misconception often lie in the situations associated with the use of short-acting intramuscular injections in emergency or inpatient settings. In addition, the first-generation antipsychotic injections are associated with a sometimes-reported higher occurrence of adverse events, including extrapyramidal symptoms, which can contribute to a negative perception of LAI treatments.¹

It’s important to distinguish between the older, first-generation injections and the more modern, second-generation LAI antipsychotics, including water-based formulations that help reduce the occurrence of injection-site-related adverse events.¹ This formulation change may provide some comfort for patients.

Additionally, the frequency of adverse events and adverse event-related discontinuations are the same or lower for LAIs than for oral antipsychotics.¹

Some healthcare providers may remain hesitant to prescribe LAIs, often due to concerns about the long intervals between doses and the management of potential adverse reactions. It’s advisable to test patients for tolerability to the LAI formulation before fully transitioning them from oral medications. Remember, if adverse reactions happen with LAI use, they can be managed.⁶

Misconception 4: “LAI treatment can be complicated. It’s best to wait until after multiple relapses or recurrences to see whether it should be initiated.”

Relapses and recurrences have significant negative impacts on the patient. Each time a person relapses, their brain structure changes and functioning declines.^7,8 This deterioration can make recovery increasingly difficult, underscoring the need for treatments that can effectively minimize the likelihood of relapse.

LAIs can reduce the number of relapses and hospitalizations, and effective treatment should be initiated as soon as possible.¹ Why wait to treat with an LAI when it can help delay the next possible relapse? The National Council Medical Director Institute recommends using LAIs over oral medications for all eligible patients, especially in early illness stages, to help prevent negative outcomes.⁴

Some healthcare providers hesitate to incorporate LAIs into their practice due to perceived logistical hurdles, such as the need for a nurse to administer the injections or concerns about the burden of the administration process. These challenges should not prevent patients from accessing LAI treatment. Alternative solutions, such as collaborating with specialty pharmacies that can administer injections, can facilitate patients receiving their treatments regularly and reliably.

Overcoming Barriers and Moving Forward

The adoption of LAIs involves conversations addressing these misconceptions directly and improving education for clinicians, patients, and their caregivers. Our goal should always be to offer patient-centered care. This means having informed, transparent discussions about all available treatment options, including LAIs. By doing so, we empower our patients with the knowledge and freedom to choose treatments that best align with their needs and lifestyles.