John M. Kane, MD: I think there are several reasons why clinicians are underprescribing long-acting formulations. First, sometimes the clinician will say, “Well, I know my patient’s adherent, so they don’t need this.” And my response to that would often be, “Well, how do you know for sure? And second, how long do you think they will be adherent?” Because it’s very hard to predict when somebody is going to become nonadherent. We don’t have a nonadherent personality or nonadherent character. Many patients who start out being adherent will become nonadherent, and we don’t know exactly when that’s going to happen. So for the clinician who says, “Well, I know my patient’s adherent,” I’m not really comfortable with that.
Another thing that we hear from clinicians is, “It’s really going to interfere with the therapeutic alliance if I say I want you to receive injections because that means I don’t trust you, and I’m going to recommend something else.” I think that’s the way we have the conversation. It should not be pejorative, it should not be, “I don’t trust you,” it should be, “This is the way we treat your illness.” It should be, “We know that it’s human nature for everyone to have trouble taking medicine. We don’t want you to be in that situation.” So those are some obstacles. I think other obstacles are clinicians don’t want to have the conversation, if the patient says, “No, I don’t like needles,” then the clinician backs off and says, “OK, that’s it.”
That’s a mistake because nobody like needles. Who is going to say, “Oh yes, please give me an injection”? You have to explain to the person why this is valuable to them, why it’s worth having the pain of an injection every other week, once a month, once every 2 months, once every 3 months, whatever it is, and how it’s not that painful.
I’ve had patients who were afraid of needles and I would say, “All I want you to do is try 1 injection and then we can talk about it, because right now it’s kind of an abstract fear, and when you see that it doesn’t hurt that much, I think you’ll be comfortable with it.” And in fact what happens is that it hurts less over time. Once you feel comfortable getting injections, it actually hurts less. So those are some aspects of the obstacles. I also hear from some clinicians, “Well what if the patient develops an adverse effect? Now you’re saying I’m going to give this medicine once every 2 months. What if they develop an adverse effect?”
We know these medicines very well. They are quite safe. There’s no adverse effect that we need to worry about if someone develops it. Even with neuroleptic malignant syndrome, there’s no evidence that it will have a worse outcome if someone is receiving a long-acting injectable. Even though we’d like to stop the drug, it doesn’t mean that the condition is going to have a worse outcome if someone is on a long-acting formulation.
The drugs are generally quite safe. Yes, they have adverse effects, things like sedation or weight gain or what have you, but we’re not talking about life-threatening adverse effects. And we need to explain to the clinicians and to the patients and families the various risks and benefits associated with any medication, with any treatment. But if we look at it in its totality, I think the benefits far outweigh the risks of these medicines in general, and of the long-acting formulations in particular. Because what we really want to do is prevent relapse, prevent hospitalization, prevent the deterioration associated with those outcomes, and help the person have a better quality of life. And this is a chance for us to really contribute to that outcome.
I think we need more educational opportunities, in general. Physicians need help sometimes learning how to do new things. Some clinicians are rapid adopters and some clinicians are slow adopters. But I think they need help in learning new techniques, new technologies. We need to do a better job in our residency training programs of helping people to use newer methods, making sure they understand the recent evidence, making sure they’re comfortable, having the conversations with patients. That’s often where it breaks down in that clinicians are not comfortable or have not been adequately trained in how to have the conversation with the patient.
We also take that for granted, right? We’re physicians so we should be able to talk about anything and explain anything, but it gets back to how we go about it, whether it’s done in a way that’s shared decision making and really explaining the benefits or whether it’s done in a way that’s pejorative or negative or critical. We need to normalize nonadherence, for example. All of these things contribute. And I think a lot of it does hinge upon our doing a better job of educating ourselves and our colleagues as to how to do this. So I hope other programs and other strategies can help clinicians do a better job. I know they all want to do the best they can for their patients, but we need to help them sometimes with new skills and new approaches.