Expanding Access to MOUD: The Psychiatric Pharmacist’s Role in Optimization

Ashley Maister, PharmD, BCCP, clinical pharmacy practitioner in mental health at the US Department of Veterans Affairs, and Aaron Salwan, PharmD, MPH, BCCP, clinical pharmacy specialist in behavioral health at Montefiore Nyack, continued their conversation with Pharmacy Times, discussing how psychiatric pharmacists optimize medications for opioid use disorder (MOUD) through independent scope of practice, protocol development, and collaboration with providers. They highlighted efforts to expand access to long-acting injectable therapies, microinduction strategies for buprenorphine, and innovative approaches to managing withdrawal from multiple substances. The conversation also emphasized the value of psychiatric pharmacist networks in managing complex cases and improving institutional care. Additionally, Maister and Salwan described how education, patient interaction, and advocacy within health care systems help reduce stigma surrounding substance use disorders.

Pharmacy Times: How do psychiatric pharmacists help optimize medications for opioid use disorder (MOUD) for patients with SUD?

Ashley Maister, PharmD, BCCP: The nice thing about working at the VA is having that scope of practice. I think that’s how psychiatric pharmacists here are really making an impact. We can do things under an independent scope of practice. Obviously, there’s still opportunity for collaboration, but that seat at the table is really important.

Specifically, some of the things that we’ve done at our facility were working toward making sure that those long-acting products that Aaron spoke about earlier were available. They’re governed, if you will, with REMS protocols and ordering and things like that. We wanted to make it easy for providers to be able to order them at the correct dosages. In terms of optimizing them, that means making sure that providers and patients not only know how to start but also how to maintain the medication.

One of the things that we worked on, too, was creating a microinduction protocol, making buprenorphine more accessible and easier to start for people who are potentially still using opioids or maybe unknowingly using opioids because of other substances they’re using. With that in mind, we’re able to make sure that there are multiple options available for people to start, restart, continue, de-escalate, or escalate, and that’s where we can really shine in optimizing what’s prescribed to the patient.

It’s hard to answer this question just specific to opioid use disorder because most patients that we see are using multiple substances, whether that’s some sort of stimulant combined with an opioid or something more sedating. We’ve learned a way to use an older medicine, phenobarbital, effectively to help patients come off benzodiazepines safely, more comfortably, and faster. We’ve really been working on executing that protocol, and in the past year we’ve had a lot of luck with it. Patients report that the withdrawal experience was much better than prior attempts using just a benzodiazepine, for instance.

Aaron Salwan, PharmD, MPH, BCCP: In my role, I’m available constantly as a consultant, so I tend to get pulled into more complicated cases where there are nuances and where the traditional approach may not work as well. At that point, we have to know where to look, know our references, and know our network. Ashley and I have a fantastic network, so we just pick up the phone and call anyone if we have a question, and that’s been really helpful.

There probably is something to say about the value of our psychiatric pharmacist network. Overall, I think that has made our interventions, our productivity, and what we do for institutions more valuable.

Pharmacy Times: What role can psychiatric pharmacists play in reducing stigma around substance use disorders within health care settings?

Salwan: As we mentioned earlier, I think the biggest way to make an impact is exposure, and not just exposure, but interaction. Ashley and I both take students early on in their training. I’ve worked with second- or third-year pharmacy students, but more commonly students in their last year, as well as pharmacy residents in their first or second year of postgraduate training.

What I try to do is interact with patients in the presence of learners and model how I was taught to interact with patients. It’s really simple—saying good morning, smiling, and giving patients time to share what they’re experiencing with a medication, whether it’s a good or a bad experience. As psychiatric pharmacists, it’s common for us to lead medication or therapy groups, and during those sessions I’m peppered with questions one after the other. Sometimes our groups go 30 or 40 minutes over because we’re answering questions, and I do that intentionally because I want patients to feel heard.

I’m using motivational interviewing and reflective listening, and I want them to know that their experience matters. Unfortunately, patients don’t always get that from other specialties, so I make it a priority that they get that from me. If I can’t do anything else, I’m going to give them that time of day.

Maister: To add a different viewpoint from health care leadership and administration, it follows the same tenets of education and making sure that people who don’t do this every day understand the importance of it. At our institution, one of the challenges of being a federal entity is that test strips for harm reduction are considered illegal or paraphernalia in some states, whereas in the state where I live and practice, they’re not. That has led to challenges.

Where we shine is educating people and helping them understand why something is important and why we want to make sure those tools are available to our patients. A lot of this ends up being interdisciplinary work in terms of who can be involved and who can assist. Advocating, providing education, and answering questions about the products we’re offering to patients helps elevate us as part of a team-based approach.