Improving Treatment Adherence With LAIs for Comorbid Schizophrenia, Substance Use Disorder

Improving treatment adherence for patients with both schizophrenia and substance use disorder requires a multifaceted approach that prioritizes patient education and involvement, Joshua Kaufman, MD, medical director of Behavioral Health and Medical Integration at Capital District Physicians' Health Plan, explains in an interview with The American Journal of Managed Care^®. Kaufman highlights the importance of psychoeducation for this patient population and emphasizes the significance of long-acting injectables (LAIs) in improving adherence, reducing the risk of relapse, and preventing hospitalizations.

This transcript has been lightly edited; captions were auto-generated.

Transcript

Can you discuss how to improve treatment adherence for patients with coinciding schizophrenia and substance use disorder?

If a patient has a comorbidity of schizophrenia and a substance use disorder, providing psychoeducation to the patient about schizophrenia, about substance use disorders, and about the importance of treatment adherence, per se, having that be a regular topic and normalized topic of discussion has been shown to increase treatment adherence. The other thing which is very important is psychoeducation, not only about the patient's psychopathology but also psychoeducation related to the patient's medications, especially with schizophrenia. Antipsychotics, like I mentioned earlier in our conversation, very unfortunately, do have very significant side effects, including side effects that can predispose someone to self medicating with substances, and side effects that can lead to medical sequelae.

Providing psychoeducation to patients around their medication and having the patient be involved in the choice of medication is also something that has been shown to improve treatment adherence because if a patient has a choice and understands what medications they're taking, they're more likely to take them. As opposed to feeling like, “This is a bottle of medication that I'm telling you you have to take, and you have to take it even if it's giving you side effects,” which is, unfortunately, historically, sometimes how things have gone. Currently, we've moved a long way past that and luckily, this is something that has become much more commonplace.

I just really want to underscore the idea of involving the patient in their treatment and planning in their treatment plan so that they know what's going on. Because, again, this is a lot to manage. Life is difficult for everybody. Life difficulties and life stressors, which are normal parts of life, on top of living with 2 serious mental illnesses of schizophrenia and substance disorders, is a risk factor for outcomes overall. And having the patient be involved in their treatment is of the utmost importance.

The final thing I'll mention, because I know this is something that has become much more common in the zeitgeist—which I'm very happy about—is the utilization of long-acting injectable or LAI medications. And this is not just for schizophrenia but also for substance use disorders. For instance, for alcohol use disorder, there is a long-acting injectable formulation of naltrexone, which is called Vivitrol. This is dosed monthly and has very good efficacy. We're treating for treating alcohol use disorder in terms of reducing cravings. In terms of opioid use disorder, there are several long-acting injectable formulations, one of which is called Brixadi, the other, which is called Sublocade. Brixadi can be dosed either weekly or monthly; Sublocade can be dosed monthly.

In terms of schizophrenia, there are several antipsychotics that come in a long-acting injectable formulation. These can be dosed either every 2 weeks, every month, and potentially even every 2 months. The benefit of that is that if a patient gets a long-acting injectable, it ensures that for that dose period of time, the patient will have a therapeutic level of medication in their system, which is going to help reduce the risk of a patient having either a decompensation or worsening of symptoms. This is specifically important because one of the most common causes of inpatient psychiatric admissions for patients with schizophrenia and the need for utilization of high levels of care for substance use disorder care is the patient stopping medication. This would include the patient stopping medication for schizophrenia, or stopping MAT, or medication or addiction treatment for substance use disorder. The idea is that if a patient stops their medication for schizophrenia, it greatly increases their risk of having a psychotic decompensation and needing to be hospitalized.

If a patient is taking a form of MAT for their substance use disorder and they stop it, that's a big risk factor for the risk of relapse, which the relapse can (1) lead to the patient needing high levels of care for their substance use disorder if they develop withdrawal symptoms that potentially can be life-threatening, for example, if the patient has alcohol use disorder. And (2) if the patient relapses, the use of substances has been shown to decrease the effectiveness of antipsychotics and also has been shown to decrease adherence to antipsychotics because if the patient is going to be using substances, it makes it more difficult for the patient to be adherent.