Long-Acting Injectables in Psychiatry and Addiction: Megan Ehret, PharmD, MS, BCPP, FAAPP, Highlights the Pharmacist's Role

As long-acting injectable (LAI) therapies gain traction in the management of psychiatric and substance use disorders, pharmacists are uniquely positioned to support their use, address patient concerns, and expand access to care. In this interview with Pharmacy Times®, Megan Ehret, PharmD, MS, BCPP, FAAPP, professor and vice-chair for academic affairs, University of Maryland School of Pharmacy, discusses the clinical advantages of LAIs for alcohol dependence and psychiatric conditions such as schizophrenia and bipolar disorder. Ehret outlines the pharmacist’s role in improving adherence, mitigating stigma, providing patient counseling, and navigating administration logistics.

Ehret also highlights the mechanism and practical considerations of extended-release naltrexone (Vivitrol; Alkermes, Inc), explores the challenges of access, and emphasizes the importance of integrating LAIs into pharmacy and primary care settings to meet the growing need for comprehensive behavioral health treatment.

Pharmacy Times: What are the key clinical advantages of LAl therapies for patients with alcohol dependence compared to oral medications?

Megan Ehret, PharmD, MS, BCPP, FAAPP: When looking at LAIs vs oral medications, one of the largest advantages is the increase in adherence. With substance use disorders, adherence is key to a treatment plan or regimen, and so that ability to have a patient stay on a medication for an increased period of time is very important.

Additionally, the increased time to relapse, so the longer it takes for someone to potentially have a reoccurrence or relapse in the illness is better, and so the better retention because of that adherence and that time to relapse is really important, and it's been beneficial more in the LAI products than with the oral products. So [the LAI products are] keeping people engaged in that treatment much longer.

Pharmacy Times: How do LAI antipsychotics impact adherence and relapse rates in patients with schizophrenia or bipolar disorder, and what patient populations benefit most?

Ehret: My favorite question to get is which patients benefit most from LAIs? I always like to answer all patients benefit potentially from a LAI. Adherence and retention within treatment and relapse rates—these increase with adherence increases with the use of LAI. Relapse rates go down when you're using those, and that's consistent between substance use disorders and psychiatric illnesses—so bipolar, schizophrenia. Getting people engaged in treatment early and often is what I like to say.

So, all populations that have the opportunity to consider this formulation for their treatment are so very important. I think if we were treating other disease states, other medical illnesses like osteoporosis or things of that sort, we're very quick to offer our patients all of these treatment options—injectables, infusions, oral medications—and we need to think about our psychiatric and our substance use disorders the very same way that we should be offering these early and often. So that way patients do engage earlier, have that adherence, increase in retention and better long-term outcomes and prognosis.

Pharmacy Times: What are the most important counseling points pharmacists should cover when initiating a patient on an LAl—whether for alcohol use disorder or for a psychiatric condition?

Vials and syringe. Image Credit: © Davizro Photography - stock.adobe.com

Ehret: So, if pharmacists are educating on the use of the LAI, it's important to approach the patient and discuss the benefits of the medication, so describing the potential for increased adherence, the lack of taking a pill every single day, the ability to engage with the provider at a frequency of their choosing. So more of that shared-decision making.

It's also important to share the details about the preparation and administration of these different products, because they're given differently—some are subcutaneous, some are intramuscular. It's important that the pharmacist engage with the patient around their comfort or ability with these different injection techniques and what it might look like reviewing all of the different adverse effects (AEs), many of them are very similar to what they might have experienced with an oral product, but it is important to talk about things that might be uniquely different with the LAIs, whether that might be injection site reactions or various things that might happen if the product might leave a little bump or a little pain there at the site that's important to know. And then really addressing any misconceptions that they have about LAIs, and some of those might be that they're only reserved for those that have treatment resistant illness or those that are non-adherent but really making it more of an acceptable treatment formulation for everyone.

Pharmacy Times: How should pharmacists address patient concerns about AEs, injection site pain, or stigma when discussing LAls as a treatment option?

Ehret: When you're thinking about some of the AEs injection site, pain or stigma that arises if we treat each of those differently. Side effects—they're very much like the oral medications, and we can mitigate some of those side effects very easily with how we administer the med, what dose we choose, what frequency we give the medication for injection site pain, I think about offering potentially a little bit of ice to the patient before and after the injection, maybe a little bit of lidocaine cream. There are some initial studies that show that those don't affect the injection at all. And when I think about stigma, I think of it treating this as you would any other medication. Think of it as an immunization, you are just potentially going to the physician or to the pharmacy for that access point. And this is just another injection, just as anything else is. And so really normalizing the process is very important for the patient.

Pharmacy Times: What educational gaps exist among pharmacists regarding the appropriate use of LAls for alcohol dependence, and how can they be addressed in clinical or community settings?

Ehret: One of the largest educational gaps that I believe still exists with pharmacists and the appropriate use of LAIs for alcohol use disorder is really stigma and fear, many of that comes from the side of the pharmacist, that they might be fearful of giving these types of injections, those that are used, some of the medications for alcohol use disorder may be given gluteal, and there's a lot of fear around that giving those types of injections. And I think education is growing and increasing. There are a lot more hands on practice training sessions available that pharmacists can engage with.

It's also important to think about our own stigma for the potential patients that we might be treating and think about how we can address this gap in care that patients might need and be a place of comfort that patients can come to for these injections. So, it's really important that pharmacists engage in the conversation with patients, and that shared decision making in determining if this is the right formulation for the patient.

Pharmacy Times: Can you speak to the mechanism of action, indication, and key administration considerations for the extended-release naltrexone product Vivitrol used in alcohol and opioid dependence?

Ehret: Extended-release naltrexone works in the same way as the oral formulation of naltrexone that’s used for alcohol use disorder. Naltrexone is a mu-opioid receptor antagonist. Alcohol triggers the release of endorphins in the brain’s reward centers—specifically the nucleus accumbens—and naltrexone blocks the opioid receptors in this area. This prevents those endorphins from activating the receptors and, in turn, decreases the pleasurable effects associated with alcohol consumption.

In opioid use disorder, the mechanism is similar. Naltrexone blocks the opioid receptors, preventing the activation that typically occurs when opioids are taken. By decreasing this reward response, the medication reduces cravings and diminishes the pleasurable reinforcement associated with both alcohol and opioid use. That’s why naltrexone—both oral and extended-release—is used for both alcohol and opioid use disorders. Vivitrol is one of the few FDA-approved treatments indicated for both conditions.

Regarding administration, extended-release naltrexone is a gluteal-only injection due to the required volume of administration, which is 4.2 milliliters. It must be administered intramuscularly into the gluteal muscle. One important consideration is that this particular injection requires aspiration for blood before administration—this is one of the few LAI products that includes this step. As pharmacists consider administering this medication, it’s critical to review the package insert carefully for all key administration considerations. Equally important is ensuring the patient is comfortable with the injection site and volume before proceeding with administration.

Pharmacy Times: How does Vivitrol compare to other treatments for alcohol use disorder in terms of efficacy, access, and patient adherence?

Ehret: Naltrexone and acamprosate are considered first-line agents for alcohol use disorder. Disulfiram is generally used as a second-line option, largely because it requires daily administration and strong motivation from the patient to maintain abstinence. The long-acting formulation of naltrexone—Vivitrol—is particularly valuable because it supports retention in treatment, which, as mentioned earlier, helps delay relapse and keeps individuals engaged in their recovery process.

However, access can be a significant challenge. Since it’s an injectable that must be administered monthly, patients require regular access to a qualified prescriber or administrator, whether that’s a physician, nurse practitioner, physician assistant, or pharmacist. A consistent barrier has been the limited availability of injection sites or clinics that provide the medication. This lack of infrastructure often becomes the primary obstacle to more widespread use of this LAI treatment.

Pharmacy Times: Among currently available LAI antipsychotics, what differentiates their use cases, and what factors should guide pharmacist recommendations?

Ehret: When pharmacists are evaluating and recommending LAI antipsychotics—whether for psychiatric conditions or substance use disorders—several key factors should guide their decisions. First, consider what the patient is already doing well on. If the patient is stabilized on an oral medication, it’s important to determine if a long-acting injectable formulation of that same drug exists. Not all oral medications have LAI equivalents, but many do, and in some cases, there are multiple LAI formulations available for a given agent.

Next, think about the desired injection frequency. Some products are administered monthly, others every 2 months or even every 3 months. The frequency with which the provider and patient are willing to engage in these appointments matters. Injection volume also plays a role—it can range from less than 1 mL to up to 5 mL, which influences both the route and site of administration. Patient comfort and preferences around the injection site (eg, deltoid vs gluteal) should be factored in.

Additionally, consider the patient’s history of side effects, cost and insurance coverage, and the availability of access points for administration. Engaging the patient in shared decision-making is essential to selecting the right LAI product to meet their individual treatment goals and preferences.

Pharmacy Times: With the growing interest in integrating addiction treatment into primary care and pharmacy settings, what role do you see for pharmacists in expanding access to LAIs for substance use and psychiatric disorders?

Ehret: Pharmacists have a critical role to play in both recommending and administering LAI medications for substance use and psychiatric disorders. I’m excited by the fact that in most US states, pharmacists now have the authority to administer these medications—only 1 or 2 jurisdictions remain where this isn’t yet permitted. This shift opens up significant opportunities for pharmacists to increase access for patients who may otherwise have nowhere to go.

We’re also seeing a concerning trend: The number of clinicians treating substance use and psychiatric conditions is decreasing. Many of the remaining providers are covering multiple sites and often rely on telehealth. This means they’re not always physically present at each location to administer injectables like Vivitrol or LAI antipsychotics. As a result, patients are sometimes left without timely access—not due to unwillingness, but due to structural limitations.

Pharmacy can help bridge this gap. In addition to supporting patients with substance use and psychiatric conditions, pharmacists can also expand access to long-acting injectables in other areas, such as infectious diseases, gender-affirming care, and more. By normalizing LAI administration in pharmacy practice, we can help meet a wide range of health care needs across diverse patient populations.